Download Guide to Good Practice Outpatients

A Guide to
Good Practice
Outpatients
Diagnostics
Therapies
Elective Surgery
A Workbook
Tools and Techniques to enable
NHS Trusts to improve the
delivery of healthcare
Further copies of this document can be obtained from:
Allan Cumming
Innovations in Care Team
Welsh Assembly Government
Cathays Park
Cardiff
CF10 3NQ
Tel: (029) 2080 1040
http://howis.wales.nhs.uk/inic
ISBN: 0 7504 3340 X
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Foreword
by the Minister for Health
and Social Services
I am pleased that Innovations in Care has
been able to produce this guide and make
it available to all organisations within NHS
Wales. It sets out a vision for sustainable
good practice within NHS Wales. Its
ultimate aim is to create a single
integrated approach to all contacts
between a patient and a trust. It
addresses the interests both of healthcare
professionals and patients.
“The importance of patients’ voices is
recognised as being centrally important
in the drive for service improvement...
“Attention will be paid to involving
patients more in decisions about their
care and in providing adequate evidence
to help patients make informed decisions”
(Improving the Health in Wales, 2001)
It is hoped that this document will act as
a catalyst for making this happen. It is
aimed at all staff who are in a position to
be pro-active in introducing improvements
and change within their organisation.
The Review of Health and Social Care,
advised by Derek Wanless made clear that
the current position in NHS Wales is not
sustainable, that hospital waiting lists are
unacceptably long, that there needs to
be integrated thinking across health and
social care boundaries, and that best
practice should be constantly encouraged.
A guide to good practice
This document helps respond to those
challenges. It has a clear aim to improve
the experience of patients and use
resources better. It is innovative, offering
a fundamental rethinking of the way in
which we provide inpatient and outpatient
services. This offers an improved service
everywhere as an alternative to simply
making patients travel to get a better
service. Better communication with
patients is at the heart of this approach.
As the Wanless report says, demand will
always outstrip supply; increasing the
capacity of the acute sector will not on
its own solve the problem of demand;
alternatives are needed. This document
gives alternatives; for example looking at
how waiting lists are prioritised and
questioning whether some referrals and
appointments are actually necessary,
using better patient communication as the
catalyst.
The need to ensure that high quality,
accurate and complete information is
being shared between a patient and NHS
organisations has become more apparent
following the highly publicised Climbié,
Bristol Royal Infirmary, and Alder Hey
scandals.
Patient involvement is vital as patients
know best what they want from their
service.
Page i
The Key Points
1. Overall aim is to ensure patient
appointments reflect clinical priority.
Patients will be seen in chronological
order and given an opportunity to
choose a convenient date. This will
minimise non-attendances and
cancellations.
2. Patient access to hospital services will
match standards and expectations,
improving patient satisfaction.
3. Communication between hospital,
patients and GPs will be better.
Significant changes are occurring across
the NHS within the United Kingdom, and
it is hoped that this document will
promote the same success as similar
programmes implemented by our
colleagues in England, Scotland and
Northern Ireland.
The Wanless report has highlighted the
need for urgent reform and the need to
modernise. Innovations in Care must
continue to find innovative ways of
dealing with the problem.
NHS organisations should adopt the
practices described in this report.
4. Patient cancellations and nonattendance rates will be reduced by
promoting shared agreements between
patients and the trust and applying new
ways of communicating with patients.
5. Hospital cancellations will be reduced
by applying better management
practices and working with staff and
patients.
Jane Hutt
Minister for Health and Social Services
6. Waiting times, and the number of
patients waiting, will be reduced by
implementing long term capacity
planning methods
This document reaffirms the importance
that the Welsh Assembly Government and
the Innovations in Care team attach to
finding innovative ways to eliminate the
suffering and uncertainty that
accompanies long waits for treatment.
Page ii
A guide to good practice
Contents
Chapter 1: Introduction
1.1
Aims and principles
1.2
Good practice points
1.3
Why patients wait
page 1
page 1
page 5
page 7
Chapter 2: Managing waiting lists
page 15
2.1
Understanding the definitions
page 17
2.2
Validation
page 25
2.3
Clinical prioritisation
page 31
2.4
Primary targeting lists
page 33
Chapter 3: Patient focussed booking
page 39
3.1
Involving patients
page 41
3.2
Generic referrals and pooling
page 47
3.3
The booking process
page 53
3.4
Pre-assessment for theatre
page 71
Chapter 4: Essential measures for managers
page 75
4.1
Activity, backlog, capacity and demand
page 79
4.2
Process mapping: Understanding the whole
page 85
4.3
Managing patient flow
page 87
Chapter 5: Analysis tools
page 89
5.1
Understanding demand
page 91
5.2
Carve out: Understanding queues
page 95
5.3
Key performance indicators: What should be monitored? page 97
5.4
Measuring follow-up demand
page 103
5.5
Statistical process control
page 105
Chapter 6: Managing change
page 111
6.1
The human dimensions
page 113
6.2
PDSA cycles: A model for improvement
page 115
6.3
Reducing follow-up demand
page 117
6.4
GP feedback systems
page 121
Chapter 7: Useful resources
A guide to good practice
page 123
Page iii
Page iv
A guide to good practice
Who should use this guide?
This document addresses two unacceptable issues: insufficient recognition
of the importance of patient centred care, and a poor use of existing
staff and resources. Both could be alleviated within the resources currently
available to the NHS in Wales. This guide is based upon evidence of what
works — some examples from Wales, some from other countries — and
using the guide will result in significant improvement in service delivery.
It should be used by all NHS Staff who are involved in the management of
patients.
This includes senior Trust management,
outpatient managers, theatre managers,
and managers of clinical services. It also
includes clinicians: medical and nursing
staff, professions allied to medicine, and
diagnostic staff.
How to use this guide
The document contains examples of good
practice, and tools and techniques. Each
tool may be used independently, or as a
part of an overall service improvement
programme.
Some chapters (especially chapters 2 and
3) contain specific guidance for
implementing systems recommended by
the Innovations in Care Team. The
remainder contains tools that may be
useful in a wide range of improvement
projects.
Acknowledgements
This guide represents tools and techniques
developed in Wales, England, the United
States and New Zealand. It draws on the
work of many people in many
organisations.
A guide to good practice
We would like to particularly acknowledge
the work of the Modernisation Agency in
England, and the Institute of Healthcare
Improvement in the United States.
Particular thanks go to the Modernisation
Agency Capacity and Demand group and
the work of Dr Kate Silvester.
Relationships to previous
documents
This policy document replaces previous
documents issued by Innovations in Care.
This includes the following documents:
Expected Standards for Waiting List
Management in Wales (November 2000).
Achieving the Expected Standards for
Waiting List Management in Wales: Self
Assessment Toolkit (December 2000).
Meeting the Expected Standards for
Waiting List Management in Wales
(October 2001).
An electronic copy of this guide can be
downloaded from:
howis.wales.nhs.uk/inic
Page v
Page vi
A guide to good practice
Introduction to
the Workbook
This workbook is a reprint of the Guide to Good Practice published by
Innovations in Care in November 2003. This version, published in March
2004, has been produced to coincide with the Innovations in Care
programme, Implementing the Guide to Good Practice.
The programme will run from April 2004
until March 2006, and will involve teams
in all hospital trusts in Wales as well as
the national Innovations in Care team.
Work will be undertaken with Trusts on a
speciality by speciality basis, and will
focus on three main threads of work.
Treating patients by chronological
order within clinical priority
The CPaT toolkit, mentioned in this guide,
has been selected as a useful tool to
facilitate communication between
managers and clinicians around issues of
waiting list management. This toolkit will
be rolled out across the NHS in Wales in
2004.
Completing the introduction of
patient focussed booking
Across Wales the work on the introduction
of patient focussed booking for new
outpatients has been impressive. The
programme will introduce key
performance indicators for booking, and
extend patient focussed booking to cover
all outpatient, assessment, diagnostic and
therapy appointments.
A guide to good practice
Capacity, Demand and Flow
The guide includes a number of analytical
and management tools. Three of these,
described as “essential tools for
managers” will be used in selected
specialities in every Trust to analyse
capacity, current demand and activity,
and to improve services. The aim of the
programme is that these tools will become
widely used across the NHS in Wales.
The Workbook
The workbook has been reprinted in a
loose-leaf format so that updates on
specific topics can be produced during the
life of the programme. Updates will
include templates, more detailed working
examples, and information from learning
networks. The Workbook also contains a
CD-ROM
with
templates
and
presentations.
The Learning network
The programme will support a learning
network, which will meet eight times each
year. Topics and dates for the network are
available from the Innovations in Care
Website.
Page vii
Page viii
A guide to good practice
Updating the Workbook
Innovations in Care will update this workbook from time to time with
additional examples from across Wales, information from learning events,
and templates to aid analysis projects. You can register to receive these
updates in two ways:
If you received your copy of the Workbook direct from Innovations in
Care, complete the registration form on the CD-ROM or enter your name
and address below, and post this page to:
Innovations in Care
Cathays Park
Cardiff
CF10 3NQ
Name
Address
Number of copies of updates required
If you received your copy of the Workbook from a Trust Improvement
Manager, please return this page to them and they will order your
updates for you.
A guide to good practice
Page ix
Page x
A guide to good practice
Chapter 1
Introduction:
Aims and principles
The Welsh Assembly Government is committed to ensuring that people
receive speedy treatment in the NHS. Improving Health in Wales states
that the aim of the NHS in Wales is to have “waiting times for elective
treatment that are as good as, if not better than, the best in the UK”
(page 14). To achieve better waiting times will mean a fundamental
rethinking of the way in which inpatient and outpatient services are
provided. This document will help NHS staff achieve those goals.
The aim of this document is that all
contacts between patients and a Trust are
managed within a single integrated
approach, and to provide tools to achieve
that end.
1
Patient choice
The patient should always be offered
reasonable choice in their appointment.
Choice means that the patient can choose
the location, the date and time, and the
consultant.
In
a
patient
Good Practice Point The reasonable
focussed service,
nature of the choice
there should be a
Standard Integrated Process
means that choice
standard way of
There should be a standard way of
may be limited to
making appointmaking all appointments within NHS
those locations
ments. The process
Trusts. The process should cover new
where clinics and/
for the patient
and follow-up outpatient appointments,
or theatre sessions
should be the same
physiotherapy, endoscopy, and
are held, dates and
whether for new or
radiology. The same principles and
times that clinics
follow-up
outprocesses should also apply for elective
and
lists
are
patient appointinpatient and day case events.
ments, for day
scheduled, and
consultants or other
t r e a t m e n t ,
investigations, elective inpatient or day staff that are qualified to perform the
case interventions.
procedure or see the patient.
There are six core principles behind this
document:
A guide to good practice
Reasonable patient choice means that
where an option is available, the patient
has the right to choose that option.
Page 1
1.1 Introduction
2
An agreed appointment
The patient will have the opportunity to
agree the date and time of an appointment with the Trust, either in person or
by telephone.
In no case should an appointment time
be notified to a patient who has not been
involved in the choosing of the date and
time.
3
5
An integrated set of policies
Trusts should have an integrated waiting
list policy.
The policy should reflect procedures
across all working practices in the Trust,
and should link into other Trust policies
such as patient record policies, admission
and discharge policy, staff leave policy,
cancelled operations policy and cancer
minimum standards policy.
Separate patient choice from
Trust performance
There will be times where patient choice The integrated waiting list policy must
conflicts with the Trust’s efforts to meet include a statement which describes the
purpose behind it.
targets or operate
Trust clinicians and
efficiently. Patients
Good Practice Point managers and the
may choose a date
Local Health Board
that exceeds Trust
Targets and Goals
(LHB) must all be
waiting
time
Goals set within a service should be
involved in the
targets.
aspirational and meaningful to patients.
development, onAs a long term goal waiting times for
going review, and
The key principle in outpatients of six days or less, and waits administration of
such a case is that for elective surgery of six weeks or less, the policy. The
should be aimed for.
patient choice is
policy must be
respected but that
signed off by the
Trust performance is
Trust Board Execnot adversely affected.
utive accountable for waiting list manageWhere patient choice is the only reason
that a target is breached, then that
patient should not be included in
performance measures.
4
Patients will be treated in turn
within agreed clinical priority
Patients are usually assigned a clinical
priority when a referral is received or they
are placed on a waiting list. Wherever
practicable, patients should be seen in
priority order.
ment, and be formally adopted by the
Trust Board.
6
Trusts should be aiming to
continually improve services
What is best practice in Wales today will
be standard practice tomorrow. Trusts
should never see good practice as a final
goal.
Trusts must continually improve
services, always seeking to make today’s
best practice normal, and to develop
new standards for tomorrow.
Within each clinical priority, patients
should be seen in the order that they
were placed on the list unless the
condition or circumstances suggest
otherwise, or good management
suggests an earlier appointment.
Page 2
A guide to good practice
1.1 Introduction
Targets
This guide will help Trusts achieve the
targets set by the Welsh Assembly
Government, the NHS Regional Offices,
and through the SaFF process. These
targets will move on from year to year as
services improve, and are not included in
this document. However, annual SaFF
targets should not be seen as the best
level of service that the NHS will ever be
able to provide.
The Innovations in Care Team recommends
that services set long term goals that
relate to what the patient wants. These
internal goals may be different to
Assembly and SaFF targets. They should
be ambitious and guide action.
Internal targets or goals should be seen
as the ultimate point to aim for — the
point at which to say “This is a service
that meets all the needs of our patients,
and which has achieved waiting times that
cannot be improved”.
Innovations In Care recommend that
services set an internal goal of a six day
maximum wait for outpatients, and a six
week maximum wait for a procedure. The
NHS may not achieve this goal in the short
or even the medium term, but until the
NHS delivers a service that meets these
goals, it should continue striving to
improve.
Improvement goals
Innovations in Care recommends that
improvement efforts focus on six key
goals. These are taken from a report on
the state of American healthcare.
Innovations in Care believes that these six
areas of improvement apply equally to the
NHS.
A guide to good practice
Safety
Healthcare is not safe, either in absolute
terms or in comparison to other industries
or activities. The NHS must continually
strive to make healthcare and hospitals
safer for patients, and Trusts should work
closely with the National Patient Safety
Agency to achieve this improvement.
Effectiveness
The NHS must continually work to improve
the effectiveness of clinical services:
• Administrative
processes and
procedures must ensure that the right
patient receives care from the right
professional in the right fashion and
location.
• Where there is evidence that a
procedure or treatment is effective,
that treatment must be offered to
those that need it.
• Where there is no evidence that a
procedure or treatment is effective,
the procedure or treatment should not
be offered.
Patient Centredness
All care should be centred around the
patient, with the patient being an active
participant in the process. This means that
decisions about care should directly
involve the patient, that full information
is provided at all stages, and that the
patient is able to be an equal in all
decisions made.
Patient Centredness involves more than
the treatment process. Improvement
efforts must include patients as active
members of the team. Groups that set
policy should involve patients. Patient
views and concerns should be
incorporated into all stages of any
redesign of services.
Page 3
1.1 Introduction
Timeliness
Care should be provided in a timely
fashion. This means that waiting time
targets within the Trust should be based
on what the patient considers reasonable.
This is why Innovations in Care recommend
six days as the long term goal for
outpatient and diagnostic procedures, and
six weeks for day case and inpatient
procedures.
What is the cost of poor quality?
Most of the time, improvement processes
in the NHS do not measure efficiency or
money saved. It is sometimes assumed
that improvement work is about increased
quality, and that increased quality means
increased cost. This is not the case. In a
high proportion of situations quality can
be improved by removing wasteful
processes, thereby
not
Good Practice Point reducing,
increasing, costs.
Timeliness also
Improvement Goals
applies to the
NHS Trusts should aim to continually
The NHS must start
administrative
improve services to patients.
process. Standards
to measure cost
Improvement should focus on:
should be set for
savings as part of
• Patient Safety;
the improvement
time taken to
respond to letters,
process. It must
• Provision of clinically effective
show that the work
and for process
services;
of
improving
times within the
• Services centred on patients;
patient care is
Trust.
Administrative proce• Services provided in a timely way; about improved
quality by reducing
dures should not
• Efficient provision of services;
waste, and must
waste staff time,
• Equity of access.
start putting figures
and
workflow
on the cost of that
through the clinical
system should happen as quickly and waste. This will show the real cash value
of innovation work, and make it easier to
smoothly as possible.
fund future work.
Efficiency
Money wasted in the health system could
have been used to treat patients. Trusts
have an obligation to provide patient care
in a way that is as efficient as possible,
reducing nonproductive practices and
waste to a minimum.
Equity
We should be providing care fairly,
ensuring that factors such as social
background, race or location do not
reduce access to care.
Page 4
A guide to good practice
1.2 Good practice points
Good practice points
There are a number of points of good practice throughout this guide. They
appear in boxes within the text. Here we present the points as a summary
of good practice.
Standard Integrated Process
Waiting Lists
There should be a standard way of making
all appointments within NHS Trusts. The
process should cover new and follow-up
outpatient appointments, physiotherapy,
endoscopy, and radiology. The same
principles and processes should also apply
for elective inpatient and day case events.
page 1
A patient should only be placed on a
waiting list when all preconditions for
treatment have been met. As a test, no
patient should be active on a surgical
waiting list unless the procedure could be
performed tomorrow if the appropriate
resources were available.
page 17
Targets and Goals
Validation
Goals set within a service should be
aspirational and meaningful to patients.
As a long term goal waiting times for
outpatients to six days or less, and waits
for elective surgery of six weeks or less,
should be aimed for.
page 2
On all waiting lists, validation should be
undertaken at the point the patient is
placed on the list, then at six months, and
again at 12 months. Where waiting lists
are longer than 18 months, validation
should be repeated at 18 months and then
at six monthly intervals.
page 26
Improvement Goals
Prioritisation
NHS Trusts should aim to continually
improve
services
to
patients.
Improvement should focus on:
• Patient Safety;
Clinical prioritisation increases waiting
times for lower clinical priority patients.
Where clinical prioritisation is necessary,
the fewest number of categories should
be used. Points-based systems, or systems
with many degrees of urgency, are not
recommended.
page 31
• Provision of clinically effective
services;
• Services centred on patients;
• Services provided in a timely way;
• Efficient provision of services;
• Equity of access.
page 4
A guide to good practice
Page 5
1.2 Good practice points
Primary Targeting Lists
Wherever patients are being selected
from a waiting list, the waiting list must
be prioritised and sorted. Waiting lists
should be sorted first by clinical priority,
and then by the date the patient was
added to the list. Patients should be
removed from the top of the list: longest
waiting “urgent” patients first, shortest
waiting “routine” patients last.
page 34
Patient Focussed Booking
All appointments where the patient
attends the Trust should be booked. The
key requirements of patient focussed
booking are that the patient is directly
involved in negotiating the appointment
date and time, and that no appointment
is made more than six weeks into the
future.
page 39
Patient Involvement
Patients should be involved at all levels
of the improvement process. Patients
should be represented on all project
teams, and patient views sought on
proposed solutions.
page 41
Copying Letters to Patients
All communications between health
professionals should be copied to the
patient. Patients must be given the right
to opt out of receiving letters. Good
practice is to write all letters to the
patient, and copy the letter to the other
health professional.
page 44
Examples of Improvement
Across Wales
Throughout the guide, boxes like this
contain examples of improvement
initiatives from Welsh Trusts and other parts
of the NHS.
These examples are not necessarily “best”
practice, but they are included as examples
of Trusts looking at the service they provide
to patients and saying “How can we
improve?”
Preoperative Assessment
Preoperative assessment should be
undertaken six weeks prior to surgery, and
should be booked using partial booking.
Preoperative assessment allows both staff
and patient to check suitability for
anaesthetic and surgery, agree the
booking date for surgery, and organise
discharge arrangements.
page 72
Managing Capacity and Demand
Staff managing services in Trusts must
have a clear understanding of the capacity
of their service, the activity levels
provided by the service, the demand on
the service, and the backlog of work in
the system. For non-outpatient work some
element of casemix must be incorporated
into the measures used.
page 75
Generic Referrals and Pooling
Referrals into Trusts should be pooled
within specialities. Referrals to a specific
consultant by a GP should only be
accepted when there are specific clinical
requirements, or stated patient
preference.
page 47
Page 6
A guide to good practice
1.3 Why patients wait
Why patients wait
There are many reasons patients wait. Traditionally, it has been assumed
that waiting times are caused by a mismatch of capacity and demand —
too many patients and too few resources. We will examine issues around
capacity and demand in Chapter 5. But there are other reasons for waits.
In this section we examine two of the biggest villains in the outpatient
system: Patients being seen out of order, and the effects of “did not
attends” (DNAs) on the smooth running of outpatient clinics.
Waiting for an appointment
Imagine that you are sitting in a waiting
room on a Monday morning. You are in your
local NHS Trust hospital, and you are
feeling very pleased with yourself. You
knew from your friends, the papers and
the TV that there were real problems with
the NHS, including long waits for
outpatient appointments. Yet you had
been to see your GP the previous week,
and received an appointment from the
hospital a few days later – for later that
week! Here you are, only ten days after
seeing your GP for what you know is not
an urgent problem, and the NHS has been
incredibly fast and responsive. You turn
to the person sitting next to you.
“Things have certainly improved since I
was here last” you say. “I only had to wait
ten days to get my appointment this time
— maybe all the stuff in the papers about
improvements to the NHS is working!”
The person next to you explodes: “TEN
DAYS! I have been waiting nearly nine
months to get to see this consultant! Why
did you get preferential treatment? They
better just wait till I get home and get
onto my newspaper. Then they’ll hear
about the efficiency of the NHS!”
A guide to good practice
You sink back into your seat, subdued.
What is going on here?
Two patients, neither an emergency,
waiting significantly different times for
their appointments. We know that as the
GP referrals are sent in to the hospital
they are prioritised by the consultant. We
know that the appointment clerks make
the appointments into the next available
slot. Why then is there such a disparity
between the two appointment waits?
The answer is simple and repeated
thousands of times across the country
every day. In this case your companion in
the waiting room has probably been
“cancelled” a couple of times. The
average wait in this clinic is ten weeks —
within the current guidelines for length
of wait. When your companion’s referral
was received, an appointment was made
for 10 week’s time. But just before the
clinic occurred, the Consultant put in a
leave form — and all the patients in the
clinic were rescheduled. Unfortunately,
all the clinics for the next ten weeks were
full (after all, there is a ten week wait,
and everyone has their appointment). So
a new appointment was made — for
another ten week wait.
Page 7
1.3 Why patients wait
What about you? Your appointment wasn’t
cancelled — but surely you would have
had to wait at least ten weeks? You were
lucky in the cancellation lottery. The day
that your letter arrived on the clerk’s
desk, so did another — from a patient
cancelling their appointment for this
week. Suddenly there was a free slot –
and as your referral was the next to cross
the clerk’s desk, in you went.
(the dotted line). The median wait is 9
weeks yet there are 32 patients waiting
over 13 weeks.
Waiting in a clinic
Patients being seen out of turn is not the
only problem associated with the traditional way of making outpatient appointments. The most common complaint
relating to outpatient appointments (after
those to do with the time between GP
referral and the hospital appointment) is
the time people spend in the clinic waiting
to see a consultant. Typically a large
number of people are waiting at the start
of the outpatient clinic; there are always
a lot of people in the waiting room, and
the clinics run late. Why is this?
Figure 1 is a graph showing all routine
referrals made to one consultant in a
typical speciality during one month.
Urgent appointments have been excluded.
The range of waiting times is from less
than one week up to 40 weeks. There is
also a cyclical nature to the booking
process — as referrals are received, they
are processed in batches, affecting the
“next available clinic” time, which may
change between batches as adjustments
are made to clinics.
Consider a typical outpatient department
such as ENT or Ophthalmology, both of
which see large numbers of patients in a
session. Assume each patient spends 10
minutes with the consultant, or 15
minutes with a registrar. Over the course
of a busy 3 hour clinic, at best 30 patients
could be seen by these two doctors. (The
actual figures are not important at this
stage.)
The extreme waits are due to clinic
cancellations — these are people who have
missed an appointment because either
they or the hospital has cancelled, and
they have been re-booked. As can be seen
from the solid line marking the 13 week
point, more people are seen within 13
weeks than outside (32 over 13 weeks, 119
within). The average wait is 10.8 weeks
On average 15% of patients do not attend
their outpatient appointment. Because
there are long waiting times for new
Time between Referral and Appointment.
One consultant, referrals received in one month
45
40
Delay in weeks
35
30
25
20
15
10
28-May-00
24-May-00
20-May-00
16-May-00
8-May-00
12-May-00
4-May-00
30-Apr-00
26-Apr-00
22-Apr-00
18-Apr-00
14-Apr-00
6-Apr-00
Referrals presented in order received
(each bar represents one patient)
10-Apr-00
2-Apr-00
29-Mar-00
25-Mar-00
21-Mar-00
17-Mar-00
9-Mar-00
13-Mar-00
5-Mar-00
1-Mar-00
26-Feb-00
22-Feb-00
18-Feb-00
14-Feb-00
6-Feb-00
10-Feb-00
2-Feb-00
29-Jan-00
25-Jan-00
21-Jan-00
17-Jan-00
9-Jan-00
13-Jan-00
5-Jan-00
0
1-Jan-00
5
Figure 1. Variation in waiting times
Page 8
A guide to good practice
1.3 Why patients wait
referrals, and medical staff are a scarce
resource the clinic is overbooked by 15%
to account for the DNAs — sensibly,
because otherwise, medical staff will be
under-utilised. This means that there are
now 35 patients booked into 30 slots for
the afternoon.
What effect does this overbooking have
on the smooth running of the clinic?
Firstly, although on average there are 15%
DNAs, crucially there is no way to know
which patients these are. A worst case for
the clinic would be for several patients
to fail to show for their appointments at
the start of the clinic, and all the
“overbooked” patients to be booked at
the end. This would mean that the
consultant time would still be wasted, but
the staff still have to stay late — definitely
a lose-lose situation.
What is done, of course, is to overbook
the start of the clinic to ensure that there
is always a steady supply of patients
waiting in the hospital to feed into the
consultant. This makes sense from the
point of view of protecting a scarce
resource, but it leads to overcrowding in
waiting rooms, and long waits — because
it is a very rare event that the DNAs are
all the first patients booked.
Of course, it is a rare event that the DNA
rate for a clinic is 15% — the 15% figure is
an average, and averages can be dangerous tools.
What is the effect of overbooking by
average amounts?
Some clinics, to be sure, will have 15%
overbooking and 15% DNAs, and in theory
the right number of patients will attend
— but NOT at the right times. However, in
the worst case from the staff’s perspective, some days there will be no DNA’s
— and they will be faced with an afternoon
of full waiting rooms, long waits and
finishing late. They will get complaints
A guide to good practice
from patients, and clerks will be blamed
for overbooking the clinics.
Surely this will be balanced by the good
days — if the average DNA rate is six
patients, and sometimes it is none, then
surely there are days when twelve
patients don’t attend the clinic? But the
chance that all twelve DNAs will be at the
end of the clinic is as rare as the chance
that all will be at the beginning. And
because these are unannounced nonattendances, even if they were all at the
end, you would not know until after the
clinic should have concluded. So everyone
stays till the end after all. The overrun
days cannot be balanced out by days when
you finish early — there are no good days
to balance the bad.
An example...
This is illustrated by Figure 2 on the next
page. The data here come from an ENT
consultant, and represent 50 consecutive
outpatient clinics. The clinics are all for
new patients, and all degrees of urgency
are included. The average DNA rate for
the 50 clinics used in this example is
14.5%. 19 of the 50 clinics have DNA rates
of less than 10%, so with an overbooking
rate of 15%, these 19 clinics were
overbooked by at least 5% and up to 15%.
Another 16 clinics had DNA rates of 10%
to 20%, giving slight overbooking or
underbooking. And 15 clinics had DNA
rates above 20% — which meant that in
these cases the clinic was substantially
under-utilised, because the “average”
overbooking of 15% was not sufficient to
compensate for the DNAs in that clinic.
In the worst case, half the patients for
one particular clinic did not attend!
What are some other consequences?
Patient surveys have shown that waits in
clinic are a major concern. Fortunately
Trusts no longer ask all patients to come
at 2pm for the clinic — but sometimes it
still seems that way. Faced with long
Page 9
1.3 Why patients wait
DNA Rates, by clinic, for one consultant, 50 consecutive clinics
60%
DNA Rate as % of "Should Attends"
50%
40%
30%
20%
10%
50
49
48
47
46
45
44
43
42
41
40
39
38
37
36
35
34
33
32
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
16
15
14
13
12
11
9
10
8
7
6
5
4
3
2
1
0%
50 Consecutive Clinics
Figure 2. Variation in DNA Rates
waits, “experienced” patients may try to
arrive early, to beat the queue, adding to
the front-loading problem.
Another problem for patients is often
parking. If a patient waits two hours in
clinic, their car spends two hours in the
car park. If each patient spends only an
hour, the number of cars parking will be
considerably reduced. The worst parking
problems are at the start of clinics – when
everyone overbooked and front-loaded
arrives at once — along with those patients
trying to beat the queue!
But overall, the negative effect of a poorly
designed clinic system is most seen in
people’s attitudes. Patients get
disgruntled. Staff get demoralised –
consultants are running a clinic where
every time they put their heads out into
the waiting room they see a sea of faces,
all eagerly awaiting their turn — and the
pressure of all those people waiting makes
them rush patients through. Complaints
increase. Parking is a problem so patients
are late, adding to the problem.
Clinic flow rates
It is important to understand how an
Page 10
overbooked clinic runs under various
situations, and compare these to how a
clinic would run if there were no DNAs.
To illustrate this, five clinic scenarios are
presented as a series of work flow charts,
Figures 3a to 3e. Before explaining the
figures, it is important to understand the
assumptions that they are based on.
The clinic described in these figures is
three hours long (2pm until 5pm) with
each patient taking approximately 10
minutes with the sole clinician. For each
patient, an “actual time” of between 5
minutes and 15 minutes has been
randomly allocated. These average out to
9 minutes, well within the ten minutes
the appointment slots allow.
No patient is late or early for their
appointment. There are no breaks in the
clinic, and under each scenario it is
assumed that the clinician does not go
faster or slower to cope with the changed
workload (which is what normally
happens). This scenario presents a
simplified view of clinic structure to make
the interpretation of the effect (overbooking) easier to observe.
A guide to good practice
1.3 Why patients wait
It is also assumed that on average the
clinic has a DNA rate of 20%. In a clinic of
18 patients, five extra have been added
to compensate for these DNAs. As already
discussed, there is no advantage to these
additional patients arriving later than a
patient who DNAs, so (in figures 3a to 3c)
the extra five patients are booked early
in the clinic — two at 2pm, and one each
at 2:10pm, 2:20pm, and 2:30pm.
On the work-flow graphs, each patient is
represented by a horizontal bar. The start
of the bar (a black line) represents the
patient appointment time. A light bar
represents a patient wait, and the dark
portion represents the time that the
patient spends with the clinician. If a bar
shows only the black portion, the patient
at that time was a DNA.
Figure 3a represents a normal clinic. The
clinic is 20% overbooked, but five patients
DNA, so the number in the clinic is the
correct number for the total time
available. There are several lengthy waits
early in the clinic, but these reduce over
time and the clinic finishes a fraction over
time, at 5:03pm. The average wait for all
patients is only 7 minutes, and the longest
wait for a patient is 21 minutes — within
patient charter standards.
Figure 3b represents one of those “good”
days. Although five extra patients are
booked, ten do not turn up. As seen in
the real case of figure 2, this happens
more often than may be thought. Once
again the DNAs are randomly allocated
through the clinic.
What impact do these five extra DNAs
have? The average wait is reduced slightly,
from 7 minutes to 5 minutes. The longest
wait for a patient is reduced from 21
minutes to 15 minutes. The major effect
is that the clinician has 42 minutes
unoccupied. The clinic finishes at the
same time!
What happens, if instead of five fewer
patients, five extra turn up — the example
of no DNAs. Figure 3c shows the impact.
Average patient waiting goes from 7
minutes to 38, and 17 patients break the
charter guidelines of being seen within 30
Clinic Flows, 20% Overbooking, 20% DNAs
02:00
02:30
03:00
03:30
04:00
Appointment Time
patient wait
04:30
05:00
05:30
06:00
1
3
5
7
Patients
9
11
13
15
17
19
21
23
time with consultant
Figure 3a. Clinic Flows, 20% overbooking and 20% DNAs
A guide to good practice
Page 11
1.3 Why patients wait
minutes (two others just scrape in at 29!)
The longest wait goes from 21 minutes to
52, but most dramatically, the total time
spent by patients in the waiting room goes
from 2 hours 16 minutes up to 14 hours 38
minutes!
Crowding also increases. In figure 3a, the
maximum number of patients in the
waiting room shortly after 2pm was four,
but this dropped rapidly. In figure 3c, this
remains at six for most of the afternoon.
The clinic finishes 43 minutes late.
What happens if the clinic is booked with
slightly shorter appointment times,
staggering the additional patients rather
than front loading them? This would
Clinic Flows, 20% Overbooking, 40% DNAs
02:00
02:30
03:00
03:30
04:00
Appointment Time
patient wait
04:30
05:00
05:30
06:00
05:00
05:30
06:00
1
3
5
7
Patients
9
11
13
15
17
19
21
23
time with consultant
Figure 3b. Clinic Flows, 20% overbooking and 40% DNAs
Clinic Flows, 20% Overbooking, No DNAs
02:00
02:30
03:00
03:30
04:00
Appointment Time
patient wait
04:30
1
3
5
7
Patients
9
11
13
15
17
19
21
23
time with consultant
Figure 3c. Clinic Flows, 20% overbooking and no DNAs
Page 12
A guide to good practice
1.3 Why patients wait
spread the increasing waits through the
clinic, catching up each time there is a
DNA. But as figure 3d shows, when there
are no DNAs the waits get steadily longer
throughout the afternoon. This scenario
also doesn’t cope well if there are several
DNAs early in the clinic.
these examples is reinforced by graphs 4a
and 4b. These combine the projections
for the examples presented plus
simulations for all numbers of DNAs
between none and ten. The graphs show
the relationship between DNAs and time
wasted with increased or decreased
numbers of attenders in an overbooked
clinic.
The final clinic presented here is figure
3e. This clinic has 18 patients (the
optimum amount). It allows 10 minutes Figure 4a shows that as the number of
per patient as do figures 3a to 3c. DNAs goes down, the total amount of
However, the average wait is only 3 wasted patient time increases
minutes. The longest wait is 8 minutes, exponentially. Figure 4b shows that the
and the total patient waiting time is 54 effect is similar but less pronounced for
minutes. No DNAs have been planned for. average and maximum patient waits.
It has been assumed that every patient
will attend, and patients have been
booked accordingly. There
Number
Total
Total
Average Maximum
Total
is no front loading of the
of
patient /
clinician
patient
patient
patient wait
patients
clinician
wait time
wait
wait
time
clinic to compensate, no
seen
contact
(all
time
patients)
shortening of appointment 20% overbooked
18
2hr 57min
6min
7min
21min
2hr 16min
slots to allow for the extra 20% DNA
20% overbooked
patients.
The table summarises the
statistics for these five
examples. Probably the
most significant fact of
40% DNA
13
2hr 21min
42 min
5min
15min
1hr 7min
20% overbooked
No DNA
23
3hr 43min
nil
38min
52min
14hr 38min
23
3hr 43min
nil
19min
37min
7hr 24min
18
2hr 59min
3min
3min
8min
54min
20% overbooked
staggered,
No DNA
No overbooking
No DNAs
Clinic Flows, 20% Overbooking with staggered appointments, no DNAs
02:00
02:30
03:00
03:30
04:00
04:30
05:00
05:30
06:00
1
3
5
7
Patients
9
11
13
15
17
19
21
23
Appointment Time
patient wait
time with consultant
Figure 3d. Clinic Flows, 20% overbooking with staggered appointments and no DNAs
A guide to good practice
Page 13
1.3 Why patients wait
Clinic Flows, No Overbooking, No DNAs
02:00
02:30
03:00
03:30
04:00
Appointment Time
patient wait
04:30
05:00
05:30
06:00
1
3
5
7
Patients
9
11
13
15
17
19
21
23
time with consultant
Figure 3e. Clinic Flows, No overbooking and no DNAs
Total time spent waiting
960
840
720
Minutes
600
480
360
240
120
0
10
9
8
7
6
5
4
3
2
1
0
Numb er of DNAs
It is clear from these examples that the
NHS has historically taken a mistaken
approach to the problem of DNAs. It has
accepted DNAs as a normal fact of hospital
existence, and has worked out strategies
to accommodate them. The approach has
dealt with the symptom of the problem,
rather than dealing with the root cause.
What must be addressed is the reason for
DNAs. DNAs must be eliminated from
clinics, and booked accordingly. Only then
will the NHS get out of the morass that
DNAs and strategies to “fix” them have
created.
Figure 4a Impact of DNAs on waiting times
Waiting times for patients and consultant
60
50
Minutes
40
30
20
10
0
10
9
8
7
6
5
4
3
2
1
0
Numb er of DNAs
Maximum wait for a patient
Average wait for a patient
Consultant time unused
Figure 4b. Impact of DNAs on waiting times
Page 14
A guide to good practice
Chapter 2
Managing
waiting lists
Sometimes it seems that the NHS is primarily about waiting lists. Public
perception focusses on waiting lists. Waiting lists provide media headlines.
For those working within the NHS, it seems that too often the real work of
staff is lost in a concern for waiting times and targets.
There is some truth to this position.
Waiting times are an easy target for the
media. Waiting times are measurable,
where so much else in the NHS is not. Many
waiting times are long. It is easy to set
targets for waiting times reductions.
There is one fundamental truth behind
this rhetoric. Many waiting times are too
long.
What can be done to reduce waiting
times? Chapters 4, 5 and 6 include a
number of generic improvement tools,
which will be useful in managing waiting
lists. But first, this section deals with basic
waiting list management: definitions,
validation, prioritisation and the use of
primary targeting lists.
Understanding the definitions
The Welsh Assembly Government uses a
formalised structure to monitor waiting
times across Wales. The definitions used
in this process are included here.
validation and provides sample scripts and
letters.
Clinical prioritisation
Clinical prioritisation is often suggested
as a key factor in managing waiting lists,
and asks what levels of prioritisation are
appropriate.
Primary targeting lists
Primary targeting lists involve the ordered
treatment of patients by referral date,
and this chapter covers how primary
targeting reduces waiting times for
inpatients and outpatients.
Managing waiting lists
There are waiting lists in the NHS because
lists are not managed well. This situation
must change. The techniques outlined in
this chapter are fundamental, and must
be adopted in the management of all
waiting lists, be they inpatient,
outpatient, or for diagnostic tests.
Validation
Validation of waiting lists must be routine.
This chapter covers the principles of
A guide to good practice
Page 15
2.0 Managing waiting lists
Pooled outpatient lists
Conwy & Denbighshire NHS Trust
The development of a pooled outpatient waiting list in the
Ophthalmic Directorate ensures that patients of the same
clinical priority are seen in chronological order. This practice
enables patients on the waiting list to be placed within a
single queue rather than multiple waiting queues and ensures
equity of access.
Objectives:
· Equalise waiting times for patient’s first appointment
· Assist in the modernisation of patient access to hospital
services
· Improve the service to patients thus improve patient
satisfaction
Booking procedure:
1. Senior Medical Officer to indicate urgency – routine or
specify when patient to be seen.
2. Indicate – diagnosis, procedure.
3. Patient entered on outpatient waiting list entry screen and
acknowledgement letter sent. No consultant selected at
this stage.
4. Patient selected in order of wait.
5. Consultant selected and entered on PAS.
6. Second letter sent to patient requesting they contact the
appointment clerk to arrange their appointment.
7. Patient contact made regarding appointment. Consultant
and location can be altered at patient’s request at this
stage.
This process came into practice September 2003 and is managed
referencing specific clinical requirements within the specialty
of ophthalmology, with subspecialties such as vitreo-retinal
surgery dealt with by the identified consultant specialist. As
the majority of ophthalmic referrals are suitable for the pool
this will make a significant difference to the equity and
efficiency of ophthalmic patient services at the point of
referral.
Page 16
A guide to good practice
2.1 Understanding the definitions
Understanding the
definitions
This section contains definitions of specific terms used through this manual.
It also contains the Welsh Assembly guidance on how patients should be
managed for waiting list measurement reasons. These definitions are
updated from previous data definitions, and will be confirmed in a Welsh
Health Circular which will also deal with issues of implementation.
Clinical Referral Date (CRD)
The Clinical Referral Date (CRD) is the
clinically significant date marking the
start of a period of waiting either for an
initial outpatient consultation or for an
episode of treatment such as elective
surgery. The CRD is used to order pick lists
used for booking patients, and it does not
change under any circumstance. It is not
used to calculate performance waiting
time statistics.
the patient for treatment. The CRD or DTA
date is used to order the waiting list for
selection of patients for surgery.
Waiting List Date (WLD)
The waiting list entry date (WLD) is
initially set as the same date as the
Clinical Referral Date (CRD). The WLD is
used to calculate waiting times for the
purposes of measuring Trust performance
against Welsh Assembly Government
performance targets. It is not used to
Outpatients
order outpatient
The Clinical ReferGood Practice Point waiting lists for
ral Date (CRD) is the
partial booking or
date that the referto order inpatient
Waiting Lists
ral of an outpatient
or day case lists for
A patient should only be placed on a
appointment is reselection
of
waiting list when all preconditions for
ceived in the Trust. treatment have been met. As a test, no patients for surgery.
All referrals should
patient should be active on a surgical
be date stamped on waiting list unless the procedure could There are a number
opening, and enbe performed tomorrow if the
of situations where
tered onto the PAS
appropriate resources were available.
the WLD may be
with the date
changed. These
stamped date as the CRD. The CRD is used include rescheduling an appointment at
to order the lists for partial booking pick the patient’s request, reinstatement to a
lists.
waiting list following removal, or where
a patient has chosen to remain with a
Inpatient and Day case events
consultant when offered an earlier
The Clinical Referral Date (CRD) or the appointment with a different consultant.
decision to admit (DTA) date is the date The circumstances where the WLD may
that a decision was made by a clinician be changed are covered in the various
within the Trust (or a GP outside the Trust definitions in this section.
in cases of direct access referrals) to list
A guide to good practice
Page 17
2.1 Understanding the definitions
The CRD or DTA date are never changed.
Did Not Attend (DNA)
Did Not Phone (DNP)
A Did Not Attend (DNA) is recorded where
a patient does not attend any
appointment or admission within the Trust
without notifying the Trust.
Any patient who does not phone in
response to a partial booking letter or a
validation letter may, once certain
preconditions have been met, be removed
from the waiting list with the reason for
removal being “DNP”
Treatment of DNPs
Under partial booking a DNP should be
recorded only where the required number
of reminder letters have been sent, and
the required time for a response has
lapsed. In most cases this will mean an
initial letter and a reminder letter have
been sent (two weeks apart) and a further
two weeks after the second letter has
elapsed.
A DNP should be removed from the waiting
list and suitable notification made.
Minimum Standard
The patient’s referring GP or GDP
should be notified that the patient has
failed to phone and has therefore been
removed from the waiting list.
Instructions should be included on how
the patient can be returned to the
waiting list (see sample letter on page
69). Instructions should also be
included on what to do if the patient
has a serious condition that requires
urgent attention.
Good Practice
The patient should be notified that
they have been removed from the
waiting list because they have failed
to respond to two requests to contact
the Trust. Information should be
included that tells the patient how to
get re-referred if they now or
subsequently have problems (see page
69).
Page 18
Treatment of DNAs
Any patient who fails to attend their
appointment or admission should be
removed from the appropriate waiting list
and suitable notifications made.
Minimum Standard
The patient’s referring GP or GDP
should be notified that the patient has
failed to attend their appointment or
admission and has therefore been
removed from the waiting list.
Instructions should be included on how
the patient can be returned to the
waiting list. Instructions should also be
included on what to do if the patient
has a serious condition that requires
urgent attention. Where the
appointment was for a follow-up
outpatient appointment or for an
admission event, the person requesting
the appointment or admission (eg the
consultant in the previous outpatient
clinic) should also be notified.
Good Practice
The patient should be notified that
they have been removed from the
waiting list because they have failed
to attend their clinic or admission
event. Information should be included
that tells the patient how to get rereferred if they subsequently have
problems.
Could Not Attend (CNA)
A Could Not Attend (CNA) is recorded
where a patient notifies the Trust that
they will not be able to attend an
appointment or admission event.
A guide to good practice
2.1 Understanding the definitions
Treatment of CNAs
First CNA
Any patient who contacts the Trust to
notify it that they will be unable attend
an outpatient appointment or admission
event should have another appointment
or event arranged at the time of the
notification. If the patient notifies by
phone, the new appointment should be
made then. If the patient notifies by letter
or email, an immediate response should
be sent asking the patient to contact the
Trust by phone to arrange a new
appointment.
At the time of contact, the Waiting List
entry Date (WLD) should be reset to the
date of the contact with the patient. In
most cases this will be the current date.
Second CNA
When a patient contacts the Trust to
cancel a second appointment the Trust
may treat the cancellation as a DNA and
not make an appointment. In this case,
the communication standards for a DNA
must be followed.
Minimum Standard
The patient’s referring GP or GDP
should be notified that the patient has
cancelled
two
consecutive
appointments or admissions and has
therefore been removed from the
waiting list. Instructions should be
included on how the patient can be
returned to the waiting list.
Instructions should also be included on
what to do if the patient has a serious
condition that requires urgent
attention. Where the appointment was
for a follow-up outpatient appointment or for an admission event, the
person requesting the appointment or
admission (eg the consultant in the
previous outpatient clinic) should also
be notified.
A guide to good practice
Good Practice
The patient should be notified that
they have been removed from the
waiting list because they have
cancelled two consecutive outpatient
clinic appointments or admission
events. Information should be included
that tells the patient how to get rereferred if they now or subsequently
have problems.
Reinstatement to the waiting list
Reinstatement to the waiting list can be
made by a reasonable request from the
patient, or by an authorised Trust
employee or the patient’s GP or GDP. The
patient will be reinstated on the waiting
list with their Waiting List Date (WLD) set
to the date of the request for
reinstatement. No reinstatement to a
waiting list should take place more than
three months from the date of removal.
In these cases the patient will require a
new GP referral.
Reinstatement will follow removal for one
of a number of reasons. Patients may be
removed because they were a DNA or DNP,
because they were a multiple CNA, or
because they failed to respond to
validation or responded that they wished
to be removed from the list.
Reinstatement may be requested in all
cases by the patient, Trust employee
(usually a clinician) or the patient’s
referring GP or GDP.
A reasonable request from the patient for
reinstatement could be either clinical
(because a condition has recurred or got
worse since removal) or social (the patient
may have been away from home when the
validation letter or partial booking letter
was received, and will ask for
reinstatement on their return). In all cases
the patient will be returned to the waiting
list with their Waiting List Date (WLD) set
to the date of the request for
reinstatement.
Page 19
2.1 Understanding the definitions
Reinstatement by Trust staff or the
patient’s GP will usually be for clinical
reasons. The GP will ask that the patient
be reinstated because their condition has
not improved and the original reasons for
referral still exist. The Consultant will ask
for reinstatement to the waiting list or
follow-up outpatient clinic because they
believe that the patient continues to need
treatment within the Trust.
In all such cases, indication should be
sought from the clinician as to what steps
will be taken to ensure the patient’s
attendance at subsequent appointments.
While a patient may be reinstated, simple
reinstatement to a waiting list or making
of a further appointment does not meet
the obligation of the clinician to see the
patient where there is a clinical need for
the reinstatement.
Where the reinstatement has been
requested by a consultant, the consultant
should contact the patient’s GP to
determine whether reinstatement is the
best option, and to enlist the assistance
of the GP in ensuring the patient’s
attendance at subsequent appointments.
Where the reinstatement is at the GP’s
request, the GP should first contact the
patient to find out why the patient did
not attend, and to ensure that the patient
will attend subsequently.
Where a request is made to reinstate a
patient to a waiting list who has been
removed from a waiting list or clinic
because of two or more non-attendances
or non-responses, the request for
reinstatement should be made through
the clinical head of the service involved.
It must be emphasised that simple
reinstatement or making a new
appointment is not treatment of the
patient, and if the patient requires
treatment, avenues must be followed that
will lead to the attendance of the patient,
not simple reinstatement.
Page 20
Change of care provider or
treatment location
Trusts may ask patients whether they are
prepared to be seen by a different care
provider or at a different location than
was originally intended. In all cases, the
patient may exercise their right of choice
and choose to remain with the original
clinician or location.
In order to reduce overall waiting times,
Trusts may pool waiting lists. This will
involve moving patients from the care of
one health professional to another, or
from one location to another. A patient
may be moved to a consultant of
equivalent sub-specialisation who has a
shorter waiting list; to a non-consultant
clinic (such as a GPSI or advanced practice
physiotherapist), or to a clinic held by the
same consultant at a different location.
All pooling after an initial offer of
information must be subject to the
agreement of the patient.
This means that where the Trust has
notified a patient that they are on the
outpatient waiting list of a particular
consultant, they must contact the patient
in person or by letter before pooling the
referral. Similarly, if a patient has seen a
specific consultant in clinic and been
placed on that consultant’s inpatient
waiting list, the consent of the patient
must be granted to transfer them to
another consultant’s inpatient list.
Where pooling is policy and normal
practice for a service, or where referrals
will be routinely seen by a non-consultant
as part of an alternative pathway of care,
individual consent does not need to be
sought from the patient. In this case it is
important that the policy and the current
practices are made clear to all GPs who
may refer into the Trust and to all staff
within the Trust, so that patients are given
clear information about pooling when they
are referred. Confirmation of the receipt
A guide to good practice
2.1 Understanding the definitions
of referral should also include a statement
about the pooling policies of the Trust (see
letter on page 68).
If the patient exercises their right to
remain with an original consultant or
clinic location their consultant or clinic
will not be changed, however the Waiting
List Date (WLD) will be reset to the date
of the decision. This means that the
patient will no longer show as a long wait
on the original list. This does not affect
their position on the waiting list however.
They will remain in their existing position
on the list for the purpose of generating
the Primary Targeting List (PTL), as the
PTL sort is done on the basis of the original
Clinical Referral Date (CRD) not the WLD.
When a patient exercises their right to
remain with an original consultant or
clinic location, they must be advised at
the time of choice that the decision may
mean that their wait will be longer than
if they accept the change. They should
also be advised that they will no longer
fall within the waiting times targets set
by the Welsh Assembly Government. Some
sample wording can be found in the letter
on page 68.
In some Trusts, routine validation of long
wait patients includes an offer to transfer
care to an alternative consultant or care
provider. In some cases the validation may
offer treatment at an alternative facility.
In these cases, the validation process
should be seen as part of the pooling
process. Where patients decline to be
pooled, their WLD should be reset to the
date of the validation letter. In these cases
the consequences of declining the offer
of pooling must be clearly spelt out in the
validation letter. This process is covered
in the section on pooling on page 47 and
a sample validation letter can be found
on page 29.
A guide to good practice
Transfers between consultants and
specialities
Sometimes patients are referred to the
wrong consultant or speciality, or a second
opinion is sought. Referrals to the
incorrect consultant, which are then
forwarded to a different consultant
within the same speciality, should be
treated as follow-up appointments.
Transfers to a different Trust (tertiary
referrals) or to a different speciality in
the same Trust, should be treated as a
new referral. Transfers from an
alternative care provider (such as a
physiotherapy triage clinic) should be
treated as a follow-up appointment.
Suspending patients
What are suspensions?
Patients may be suspended on both
inpatient and outpatient waiting lists. The
rules for suspension are the same for all
cases. Patients can only be suspended for
a period of up to six months, with the
exception of suspensions for pregnancy.
Where the patient is not available for
treatment at the end of six months they
will be removed from the waiting list.
Patients can be suspended for two
reasons; either because they are
medically unfit for surgery (medical
suspensions) or because they have nonmedical reasons why they are unavailable
for surgery or the appointment (social
reasons).
A patient cannot be re-suspended for the
same reason after the six month period is
up. A patient may be re-suspended for a
period for a different reason. For
example, a patient may be suspended for
social reasons for a period of three months
and then found to be unfit for surgery at
pre-assessment. They could be suspended
for further six months to stabilise their
medical condition.
Page 21
2.1 Understanding the definitions
Medical suspensions
Patients are suspended for medical
reasons when they are temporarily unfit
to undergo the procedure for which they
are waiting. One example of this would
be when a patient is seen in a
preoperative assessment clinic and found
to be unfit for surgery.
Patients suspended for medical reasons
can only be suspended for a maximum
period of six months. There must be robust
mechanisms in place to deal with the
reason for the suspension. In cases where
the patient is unfit for surgery a plan must
be in place to ensure that when the
suspension period ends, the patient will
be fit.
Where the responsibility falls on the
patient’s GP to ensure that their medical
reason for suspension is dealt with, the
Trust must have in place processes to
ensure that the GP is notified of;
• the suspension and the time limit on
the suspension;
• the clinical actions that need to be
taken to ensure that the patient is fit
for surgery;
• and the consequences of the
suspension period ending while the
patient is still unfit.
If the patient is not fit by the end of the
six months, they will be removed from the
waiting list and not placed back on the
list until they are fit for surgery.
In one case the maximum period of six
months can be extended. In the case of
pregnancy, a patient may be suspended
for a period of longer than six months,
provided that an end date is recorded.
Where a patient is admitted for surgery
which is subsequently cancelled because
Page 22
the patient has an underlying medical
problem, the patient is managed as a
suspension for medical reasons.
Social suspensions
Patients are suspended for social reasons
when they are unavailable for their
appointment or admission for reasons
other than a medical condition. One
example may be a patient going overseas
for a period, or a student may be studying
away from home. A patient may also be a
social suspension if they are unavailable
because they are caring for a relative.
When the patient notifies the Trust that
they are unavailable for an appointment
or admission for social reasons, the end
point of the suspension will be the point
at which the patient becomes available
for treatment.
Where a patient is suspended for social
reasons, the maximum period of
suspension will not be longer than six
months.
The patient’s suspension from the waiting
list should end automatically at either the
negotiated date or after six months,
whichever is sooner.
Administrative processes after
suspension
It is unlikely that a patient will be able to
have their admission or their appointment
the day that their suspension ends. Once
a suspension ends, the patient will feed
back into the normal administrative
process described elsewhere in this
document. This means that there will be
a period of up to six weeks from the time
the patient is available for an
appointment and the appointment
occurring. Where patients are close to
maximum waiting times at the point of
suspension, this may mean that the
normal partial booking approach will lead
to waiting list breaches.
A guide to good practice
2.1 Understanding the definitions
For this reason it is recommended that
Trusts differentiate between when a
patient is available to make an
appointment and when the patient is
available for the appointment. Patients
will be available for an appointment or
admission six weeks subsequent to being
available to make the appointment. This
six weeks should be built into the
suspension period, and the patient
contact process should start six weeks
before the end of the suspension. Two
examples should make this clear.
Patient A is going overseas, and will not
be available to make an appointment until
their return. If they are going overseas
for ten weeks, they will not be available
to make an appointment until week
eleven. Because partial booking covers a
window of up to six weeks, the patient
may not attend an appointment until
week sixteen. The suspension should
therefore be set to 16 weeks, not ten.
They should receive the partial booking
“phone in” letter in week ten, six weeks
before the end of the suspension period.
Patient B is booked for surgical preassessment, but at the pre-assessment
clinic they are determined to have an
underlying medical problem that can be
stabilised in three months (13 weeks). A
letter is written to the GP explaining the
course of treatment required over the
three months, and the patient is
suspended. Patient B will be available for
pre-assessment in 13 weeks. They are not
out of contact so before the end of the
13 weeks the booking process can
recommence. Because there is a delay of
up to six weeks but typically four weeks
between letter and pre-assessment
appointment, and because there is no
point to bringing the patient to preassessment before 13 weeks, the “phone
in” letter should be generated in week
nine. The suspension should exceed the
phone in date by six weeks, so the
suspension should be set to 15 weeks (not
A guide to good practice
13) and the phone-in letter generated six
weeks before the end of the suspension
period.
Deferments where a patient has
not complied with instructions
In some cases surgery or investigative
procedures require that the patient
undergo a period of preparation at home
prior to admission or attendance. One
example would be the requirement to fast
before surgery; another would be bowel
preparation before colonoscopy or barium
enema. Sometimes patients attend their
admission or appointment without having
completed the required preparation, and
the procedure cannot be completed.
In these cases the patient should be
treated as a CNA. Time must be taken to
explain to the patient why the procedure
cannot be undertaken, and the new date
for the procedure should be negotiated
with the patient. It is also important that
the preparation instructions are discussed
fully with the patient or their carer so that
the situation does not recur. The WLD will
be reset to the current date as part of
the CNA process, and multiple
noncompliance would also fall within the
CNA process.
Where a particular procedure has a high
degree of noncompliance it is important
to review the literature and instructions
sent to the patient to determine if they
are clear. Alternative methods of
conveying the required information to the
patient should be investigated.
Reasonable offer
An essential part of these definitions is
that any offer to the patient is reasonable.
Where patients are being removed for DNA
or CNA the appointment must have been
for a reasonable offer of appointment or
admission as defined below. Patients
cannot be removed for DNA or CNA where
a reasonable offer did not exist.
Page 23
2.1 Understanding the definitions
Where a patient does not agree to an offer
defined below as reasonable, they may,
at the discretion of the Trust, be recorded
as a CNA. However, a suitable
appointment should still be agreed. The
recording as a CNA purely affects the
recording of the waiting time on the Trust
performance monitoring systems.
Normal outpatient appointment
A normal outpatient appointment may be
an appointment of any clinical priority. A
reasonable offer must include the
following factors:
• The patient must have been involved
in agreeing to the appointment date
and time, either by phone or in person;
• The patient must have been offered a
choice of at least three possible dates
and times, one of which must be at
least four weeks into the future.
• The appointment will normally be at a
Trust site, with Trust clinical staff. If
the appointment is offered at a site
outside the boundaries of the Trust,
transport must be offered from a Trust
facility. If non-Trust staff will be used,
the patient must be advised at the time
of the booking being made, and the
patient advised that if they choose to
decline the appointment, their waiting
time may increase.
Outpatient appointment under two
weeks
The short time frame involved with
organising two week waits usually
precludes the possibility of writing to the
patient and asking them to phone the
Appointment Centre.
In this case, the patient must still be
involved in the appointment process. It
may be necessary to phone the patient,
the appointment may be arranged while
the patient is at the GP surgery, or the GP
may hand the patient a form asking them
to phone the Appointment Centre.
Page 24
The patient must be offered a choice of
two date/times for the appointment, at
least one of which must be more than 24
hours into the future.
Diagnostic procedure
Diagnostic Procedures should work to the
same definitions of reasonable as
outpatients.
Therapeutic outpatient appointment
Therapeutic Services should work to the
same definitions of reasonable as
outpatients.
Inpatient or Day case admission
The inpatient and day case admission
process should be treated as a two stage
process.
Preoperative Assessment
The preoperative assessment may be
undertaken by phone or in person. Good
practice is for on-site preoperative
assessment, so that consent may be taken
during the assessment appointment.
If the assessment is done by phone, the
patient should be sent a letter asking
them to phone the clinic at one of a
specific set of dates and times. There
should be at least four date/time
combinations, and one should be at least
four weeks into the future.
If an on-site clinic is held, the same
parameters apply as for an ordinary
outpatient appointment.
Surgical admission
The date and time for admission should
be agreed while the patient is present at
the
preoperative
assessment
appointment. The patient should be given
a choice of two admission dates within
the six weeks following the assessment.
A guide to good practice
2.2 Validation
Validation
Over time, waiting lists become out of date. Patients may require
treatment when they are first added to the list, but circumstances may
change. They may choose to have treatment at another location (either
in the NHS or in private practice). They may move to another town. Their
condition may improve so that treatment is not required. Or they may
die. Systems must be in place to ensure that these patients are removed
from the waiting list.
What does validation achieve?
Validation ensures that figures of patient
numbers waiting are accurate. Where
waiting lists are high, Trust performance
may appear to be worse than it actually
is if waiting lists contain high numbers of
people who are not actually waiting for
treatment. This may affect the
commissioning process, as the perception
may be that there is a more significant
volume to be treated. It may affect
information given to patients, who will
think that they may have a longer wait
than is actually the case. It may also lead
to wasted clinical time if clinics are
booked through traditional systems and
patients not requiring to be seen are given
appointments for treatment.
Patient focussed booking and
self-validation
Patient focussed booking (partial booking)
is often referred to as self validating. This
is because no action is taken by the Trust
to allocate resources to the patient’s care
until the patient has contacted the
appointment centre and confirmed that
they will be attending, and a date for
treatment is agreed. For this reason, it is
assumed that validation is not necessary
once patient focussed booking is in place.
A guide to good practice
This is only true when the maximum
waiting times for treatment are short.
While patient focussed booking will
validate patients before they are called
for treatment, it does not do so until the
patient reaches the top of the waiting list.
Where waiting times are long, waiting lists
will remain inflated if the lists are not
validated at interim stages.
Frequency of validation
There is a need to balance the gains from
validation against the time and cost of
undertaking it. More importantly, there
are issues to do with the reaction of
patients and their GPs to the validation
process. Innovations in Care recommends
six monthly validation to achieve this
balance.
Cost of validation
Validation can be done by mail or by
telephone. Either includes a cost. Mail
validation will have costs associated with
letter production and postage, phone
validation will have costs associated with
phone charges, but by far the most
significant cost in both cases will be for
the staff time involved. It is vital to
balance the benefits of validation against
this use of resource. It is also important,
Page 25
2.2 Validation
where validation is done, to get the best
value for the money spent.
Mail validation letters must be clear and
targeted at identifying those patients who
have either had their surgery, or whose
condition has improved so that surgery is
no longer necessary. Simple requests as
to whether the patient wishes to remain
on the waiting list are inadequate.
communication that a patient receives
from a Trust is a three monthly letter
asking whether they wish to remain on
the waiting list, it is easy to see why they
may become annoyed. The more frequent
the validation and the longer the list, the
more patient perception of the process
will become a problem.
Previous documents from Innovations in
Care recommend three-monthly
validation. Frequent validation will have
diminishing returns, with fewer removals
each time the validation is performed.
Validation letters must be clear and
unambiguous. The validation process
involves removal of patients from the
waiting list if they
do not respond to
Good Practice Point Most removals come
the
validation
from the first
letter, and this must
validation. There
Validation
be made clear to On all waiting lists, validation should be are a number of
the patient. Rereasons for this:
undertaken at the point the patient is
moval of non- placed on the list, then at six months,
patients
are
responding patients and again at 12 months. Where waiting removed from a list
must be completed.
because they have
lists are longer than 18 months,
Where patients are
had surgery elsevalidation should be repeated at 18
not removed from
where, or because
months and then a six monthly
the list despite nontheir condition has
intervals.
response,
they
changed. For a
should be told why
number of less
their name has been reinstated.
serious problems, improvement is more
likely to be in the first six months. There
Telephone validation should be scripted. will be a high removal rate for this
Questions should be phrased such that the validation.
desired information is elicited; asking a
patient whether they wish to remain on
the waiting list will result in fewer
removals than questions that ask if the
patient is still having clinical problems.
It is also important to make clear to the
patient that there are mechanisms for
getting back on the list if their condition
worsens within a specific time period.
Sample phone scripts and letters can be
found on page 29.
Innovations in Care recommends that
subsequent validation be done at intervals
of six months. There is no need to do
validation close to the appointment time,
so where waiting times are 12 months a
second validation would be unnecessary.
Similarly, where the speciality is working
to an 18 month target, the 18 month
validation would not be required as the
partial booking process will satisfy the
validation requirements.
Patient responses to validation
Validation can be an imposition on
patients, and too frequent validation will
lead to patient complaints. If the only
Timing of validation
There are two ways in which validation
can be timed — in bulk or continually. The
trust may decide to do bulk validation at
Page 26
A guide to good practice
2.2 Validation
six monthly intervals — all ENT validation
in February and August for example. This
approach has disadvantages. The
validation workload is intensive, and if
done episodically, will lead to significant
peaks in workload. Additionally, the
purpose of validation is to link it to the
patient process, and if a speciality
undertakes six monthly validation
exercises, patients will be validated at
less than six months on the list, or may
wait up to 11 months before being
validated. For this reason, where bulk
validation is the only option, it needs to
be done more frequently
Continual validation can be generated by
the PAS. Procedures in the PAS should
automatically generate validation letters
at the point where the wait hits six and
12 months. The advantage of this is that
there are small numbers of letters
generated every week, rather than very
large numbers every few months, and the
validation process can be handled as part
of the ongoing work of the department
rather than as an infrequent additional
task.
Continual validation also ensures that
small numbers of patients are removed
each week, rather than large numbers at
the end of a longer period. Infrequent
“bulk” validation will lead to artificial
peaks and drops in patient waiting list
numbers, where continual validation will
not.
The validation process at referral
Validation of patient data at referral is
not normally thought of as validation, and
is often overlooked. On referral, and at
each subsequent stage of the
administrative process, all patient details
must be verified. This must happen on
referral, at each outpatient appointment,
when the patient is placed on a waiting
list, at the pre-operative assessment and
at admission. If the details differ from the
PAS, it must be updated!
A guide to good practice
Placing the patient on the outpatient
waiting list
GPs re-refer patients to the same Trust,
and to different consultants within the
Trust. When a new referral is received,
the first step should be to see if that
patient is already waiting for an
appointment, or is currently on the
inpatient waiting list for that speciality.
If so, the GP should be contacted to
determine why the patient has been rereferred.
As part of the patient focussed booking
process, it is necessary to contact patients
by mail and sometimes by phone. It is vital
that up to date information is stored on
the PAS to allow that contact to happen.
On receipt of a referral from a GP, the
referral must be checked by clerical staff
to ensure that all necessary information
is included. Where it is not, the GP must
be contacted and the full demographic
information requested. Patients must not
be added to waiting lists with incomplete
demographics.
Where a referral is incomplete and not
flagged by the GP as urgent, it should be
recorded as received but returned to the
GP practice with a form requesting the
remaining information. The form should
note that the referral cannot be received
or actioned without complete
demographic information. Where the
referral is flagged as urgent it should be
processed as complete but the GP practice
should be contacted by phone for the
remaining information.
Demographic information received at
referral may go out of date when the
waiting times are long. The partial
booking acknowledgement letter must
include a request that the patient phone
the Trust Appointment Centre if any
demographic details change while the
patient is on the waiting list. This will
ensure that records are kept up to date.
A sample letter is found on page 68.
Page 27
2.2 Validation
Placing the patient on the elective
waiting list
When a patient is listed for a diagnostic
procedure or surgery, it is imperative to
check the demographic details at that
point. The person placing the patient on
the list should confirm the demographic
details with the patient present, and
ensure that inaccuracies are corrected.
Clinical validation can be undertaken by
GPs or by Trust staff. In the case of
outpatient referral waiting lists, it is by
default the GP who will need to undertake
the validation. The Trust may supply the
practice or the LHB with practice based
lists of patients waiting for an outpatient
appointment, and the medical records of
those patients are reviewed to ensure that
the patient still requires the appointment.
Although the review process is undertaken
in primary care, any contact to the patient
advising them that their status has
changed should be undertaken by the
Trust, which has requested the validation.
As with the outpatient acknowledgement
letter, the letter confirming placement on
a diagnostic or treatment waiting list
should include a request to contact the
Trust appointment centre if any
demographic information changes.
Key Validation Points
Administrative
validation
Administrative
validation
is
undertaken
by
management and
clerical staff, and is
primarily designed
to
determine
whether
the
patient details are
correct,
and
whether
the
patient wishes to
remain on the
waiting list.
Check that a patient is not already on a
waiting list before adding them.
Check the patient details at every stage
of the administrative process.
Validate continually, rather than in
batches.
In the case of
validation
of
diagnostic
or
treatment lists, the
clinical validation
can be performed in
the Trust, or in
primary care, or
both.
Balance the advantages against the cost
of validation when determining the
frequency of validation.
Trust based validation can be either
a review of the
notes, or a clinical
Validation should be undertaken on a
reassessment of the
six monthly basis as a minimum.
patient.
Notes
review
will
have
Carefully check wording of validation
limited value, as it
letters, and telephone scripts.
is unlikely that any
Undertake clinical validation where
information will be
Administrative
possible, in addition to administrative
included in the
validation
is
validation.
record that will not
undertaken by mail
have already been
or by phone and has
already been covered. Sample letters and acted upon. However there can be
considerable value to bringing patients
scripts will be found on page 29.
into the Trust for reassessment if they
have not been seen for some time.
Clinical validation
Clinical validation is a more complex, and
more time consuming, process. The These review appointments can be with
purpose of clinical validation is to consultant staff, but may also be by
determine whether the patient’s clinical appropriately trained Allied Health
condition has changed in any way that may Professionals, such as physiotherapists or
lead to their removal from the waiting list. nurses working to predetermined
protocols.
Page 28
A guide to good practice
2.2 Validation
GP based review of treatment waiting lists
will also identify those patients whose
condition has rendered them unfit for
surgery. The GP may be treating the
patient for an unrelated problem, which
has arisen since initial referral, and would
now mean that treatment is not possible.
GP validation would normally be done by
notes review, although in the case of
patients who have not been seen for some
time in primary care, it may be necessary
to see the patient.
Dear ...,
You have been waiting for an appointment to
see Dr... since ...date.... You have not been
overlooked and your appointment is still
pending.
Sometimes patients change address or decide
that they no longer want to see the Consultant
and forget to let us know. So that we are sure
that we have the correct details we write to
patients about every six months to check.
We may be able to offer shorter waiting times
with a different consultant. If you do not wish to
be offered a shorter waiting time with a
different consultant, please indicate this on the
form.
To keep our records up to date please
complete the form overleaf and return it to me
in the enclosed reply-paid envelope.
If you need any further help please do not
hesitate to contact me between 9am and 5pm
Monday to Friday on ...
Validation Phone Script
Yours sincerely
The following questions should be asked,
using the wording provided:
Good morning / afternoon / evening.
My name is ... and I work for the ... NHS Trust.
I am phoning you about your referral to see
Dr... in the ... Department.
Are you still having the problem that your GP
referred you to Dr... with?
If yes:
Do you still require an appointment to see Dr...
If no:
In that case, is there any reason why you need
to remain on the waiting list for Dr...?
If removed:
Please tick whichever applies to you:
o
o
o
o
o
I still want an appointment
I have an appointment and I am going
to keep it
I have had my appointment elsewhere
so I no longer need an appointment
I no longer want an appointment in this
consultant’s clinic
I wish to remain with the current
consultant, even if this means I may
wait longer for my appointment
If you no longer want the appointment
please discuss this with your GP
You can be asked to be put back on the waiting
list if your condition gets worse in the next
three months. If that happens, please phone
012 345 6789 or contact your GP.
If you have any comments to make about your
choices, please write them below
Can you please confirm that the following
contact details are correct (check
demographics)
If they have please write the new one below.
Please let us have any home, work and mobile
phone numbers.
Do you have any questions about your referral
or anything else I can help you with?
Thank you for allowing me the time to ask you
these questions.
A guide to good practice
Has your address or phone changed from
those at the top of this page?
Address ...
telephone: home... work ... mobile ...
Validation letter for inpatient, outpatient or
day case surgery
Page 29
2.2 Validation
Conwy and Denbighshire NHS Trust
Validation Information Leaflet
produced by the
Data Quality Team.
These are the answers to some of the questions patients regularly ask when they
receive their first letter from us.
Why are you sending me these letters?
· We need to make sure our records are kept up to date so it is essential that when you
receive one of these letters you return it fully completed. It is important to remember that
if you change your mind about coming to clinic or having your procedure, you must let
us know straight away. Your appointment could be given to someone else. If you don’t
keep your appointment for any reason it means that somebody else has to wait a little
bit longer for their appointment.
How long will I have to wait for a date?
· This depends on which Consultant and Speciality you are waiting to see and the reason
you are waiting. We are doing everything we can to keep your waiting time as short as
possible.
· The Data Quality Team can give you an up to date waiting time. If they are unable to
help you they will put you in touch with somebody who can.
What do I do if I want the date of my appointment to be deferred?
· Some patients ask to be deferred because they are pregnant, working away from home,
or not ready for a visit to hospital. You will still be sent an administration letter. This is
because you may change your mind about your appointment/ procedure or may change
your address. However we are still aware that you wish to be deferred and that you still
require an appointment. You will not be forgotten.
What happens if the hospital cancels my appointment?
· If your appointment is cancelled by the hospital, you will still receive an administration
letter. This is because you are still on the waiting list but just waiting for an alternative
date.
· Only if you, your GP or the Consultant decide, will your name be removed from the
waiting list. If you do not let us know you have been treated elsewhere we will still send
you these letters.
Do I need to let the hospital know if I change address?
· It is important for you to let us know as quickly as possible if you are moving to a new
address. If we are not able to contact you, you could be removed from the waiting list.
· You also need to tell your GP your new address.
Information leaflet produced by the Conwy and Denbighshire
NHS Trust, sent out with all validation letters
Page 30
A guide to good practice
2.3 Clinical prioritisation
Clinical prioritisation
Traditionally patients on waiting lists have been prioritised according to a
simple system: they are either “Urgent”, “Soon” or “Routine”. These
categories are used for both inpatient waiting lists and for newly referred
patients awaiting an outpatient appointment. Little thought is given to
definitions for these terms, yet they have been fundamental to the
development of waiting lists.
The “traditional definitions”
For outpatients, “urgent” has traditionally
meant that the patient needs to be seen
within two weeks. “Soon” patients should
be seen within six weeks, and “routine”
patients have no maximum time
requirement. For elective surgery, the
same terms are used, but there are no
agreed corresponding time periods.
methods of prioritisation. Some of these
prioritisation techniques, such as those
developed in the late 1990’s in New
Zealand, do manage to prioritise patients
in ways that correspond more to clinical
need, and some of these methods have
been adopted by some Trusts in Britain.
Carmarthenshire NHS Trust has also
developed a prioritisation system used in
other Trusts in the UK with some success.
These definitions
Good Practice Point There is a fundmean very little
where waits for
amental flaw in all
Prioritisation
patients classified
prioritisation
Clinical
prioritisation
increases
waiting
as “urgent” can be
methodology
times for lower clinical priority
as long as nine
however. As soon as
patients.
Where
clinical
prioritisation
is
months. Reviews of
prioritisation is
necessary, the fewest number of
both inpatient and
used to ensure that
categories
should
be
used.
Points-based
outpatient waiting
one patient relists also show that systems, or systems with many degrees ceives treatment
of urgency, are not recommended.
within a waiting list,
ahead of another
patients classified
based on any
as
“routine”
criterion other than
frequently wait much shorter time periods time waiting, some patients will wait
than those classified as “soon” or longer. “Jumping the queue”, no matter
“urgent”. There is little evidence that that it is for the best of reasons, means
clinical prioritisation affects the amount that those at the back of the queue will
of time a patient waits.
have to wait longer. The higher the degree
of prioritisation used, the longer those at
the back of the queue will wait.
Prioritisation
Many projects have been run throughout
the world to develop more effective
A guide to good practice
Page 31
2.3 Clinical prioritisation
Indeed the problem can be worse than just
delaying those patients with a low priority.
Where there is not excess capacity over
the demand, patients with a low clinical
priority may never be seen — these
patients are those at the back of the
queue always being “pushed aside” by
those with greater need (see figure 5).
Overall, the best way to ensure that all
patients wait the shortest average time
is to have no clinical prioritisation at all,
and to see each patient strictly in turn
The key to good prioritisation is
consistency of use (from patient to
patient, across staff within a department)
and ensuring that patients within each
category are seen in strict date order. The
problem with current systems is not so
much the categorisation system used, but
the way in which it is used. Prioritising a
patient as “urgent” (i.e. needs to be seen
in two weeks) when there is a waiting list
of nine months for urgent patients is
meaningless and makes the system
pointless.
Patients
removed
from the top
of the list
Patients
added
according to
priority
high priority
Multiple
levels of
increasing
clinical
priority
Waiting
List
These
patients
may never
be seen!
low priority
Figure 5. The danger of excessive clinical prioritisation
according to when they were added to the
waiting list. However, unless there is a
very short waiting time, there is always
going to be clinical risk if some patients
wait too long. In these situations, a level
of prioritisation should be used.
What sort of prioritisation?
The best form of prioritisation, if it must
be used, is one with the fewest categories.
Prioritisation systems based on complex
points systems will add little value, and
will take time to administer. The simple,
original, “Urgent, Soon, Routine” is in fact
a good degree of prioritisation to use in
most situations where there are long
waiting times. Where waiting times are
under six months, the “soon” category
becomes unnecessary and should be
abandoned.
Page 32
Finally, the important thing to remember
about clinical prioritisation is that it is
all about patients waiting. Prioritisation,
like triage in emergencies, is a way of
ensuring that no harm comes to those who
have to wait. The best and most reliable
way of achieving that goal is to have no
waits. If everyone is seen within two
weeks, then no-one will have their care
compromised by waiting longer than two
weeks — irrespective of the method of
prioritisation used. The best method of
safely and effectively prioritising patients
is to ensure that no-one waits.
A guide to good practice
2.4 Primary targeting lists
Primary targeting lists
As has already been shown, one of the main causes of long waiting times
within the NHS has been the tendency for patients to be treated out of
turn. In this section we look at how “primary targeting lists” can prevent
patients being seen out of turn, and how they can reduce long waiting
times.
What are primary targeting lists?
Primary targeting lists are sorted by
clinical priority first, and within each
clinical priority by waiting time. Waiting
time for sorting the primary targeting list
is measured from the patient perspective,
not the Trust perspective. Waiting times
used as a Trust performance measure are
calculated by subtracting the current
Waiting List Date (WLD) from the Current
Date, and then subtracting periods of
suspension. Sorting within the clinical
priority of the PTL is done by subtracting
the Clinical Referral Date (CRD) from the
current date and ignoring periods of
suspension. This calculation ensures that
patients are seen in the order that they
Primary targeting lists are simply a way
of sorting waiting lists, and a set of
procedures for ensuring that patients are
removed from the sorted list in order. The
system of booking outpatients described
in chapter 3 incorporates primary
targeting lists, however “PTLs” should be
used wherever a waiting list exists.
Figure 6 shows the consequences of not
using primary targeting lists. It shows data
from some 500 routine priority patients
seen in an outpatient clinic, and
illustrates the variation in how long each
patient waited.
Time between referral and appointment, Consultant "A"
50
Of the over 500 cases plotted, one third
(to the left) waited over 13 weeks (the
horizontal line) — yet the median wait
(the vertical line) was below 13 weeks. A
couple of patients waited nearly 40
weeks, yet many routine patients waited
only a few weeks (those to the right of
the graph).
40
wait (in weeks)
30
20
10
496
485
474
463
452
441
430
419
408
397
386
375
364
353
342
331
320
309
298
287
276
265
254
243
232
221
210
199
188
177
166
155
144
133
122
111
89
100
78
67
56
45
34
1
23
12
patients
wait in weeks
maximum
Figure 6 Distribution of waiting times
A guide to good practice
Page 33
2.4 Primary targeting lists
are referred rather than being returned
to the end of the list because they have
changed their appointment and had their
Waiting List Date reset. The Waiting List
Date and Clinical Referral Date have
specific definitions detailed on page 17.
PTLs in outpatients and
diagnostics
The use of PTLs in outpatient waiting lists
is reasonably widespread, and PTLs form
the basis of outpatient partial booking
(covered in Chapter 3). New referrals are
sorted by clinical priority, usually
This way of ordering of the PTL has one “Urgent”, “Soon”, “Routine”, and then by
clinical referral
consequence that
Good Practice Point date within each
must be guarded
priority. Patients
Primary Targeting Lists
against. Where a
are removed from
patient is offered
Wherever patients are being selected
the top of the list —
an appointment
from a waiting list, the waiting list must all “urgents” before
and is unable to
be prioritised and sorted. Waiting lists
any “soons”, all
agree to a suitable
should be sorted first by clinical
“soons” before any
date, their WLD will
priority, and then by the date the
“routines”.
be reset. Because
patient was added to the list. Patients
only the WLD is re- should be removed from the top of the
This may cause
set, and the list is
list: Longest waiting “urgent” patients
problems where
sorted on the CRD,
first, shortest waiting “routine” patients
there is a large
the patient will
last.
backlog of “urgent”
remain at the top of
or “soon” referrals.
the PTL. If call in
letters
are
generated automatically, the
Primary Targeting Lists
patient will be called again when
the next cycle of letters is
generated. Where this is likely to
Top of the list
be an issue, it may be necessary to
either flag these records in some
way or to exclude them from the
PTL for a specified period of time.
Longest Wait “Urgent” Patient
One option would be to suspend
such patients for a period of 4
Shortest Wait “Urgent” Patient
weeks, and if this can be
automated it is probably the best
Longest Wait “Soon” Patient
Patients
solution as suspended patients will
Added
not receive call in letters.
Primary targeting lists are very
simple to explain to staff, and easy
to administer. They are notoriously
under-used despite this. There is a
need to put in place monitoring to
ensure that primary targeting lists
are being consistently used in the
administration of all waiting lists.
Shortest Wait “Soon” Patient
Longest Wait “Routine” Patient
Shortest Wait “Routine” Patient
Figure 7 Distribution of waiting times
Page 34
A guide to good practice
2.4 Primary targeting lists
In this case, using the PTL will mean that
for a significant period, all clinic slots will
be taken up by “urgent” and “soon”
patients.
Clinically this is an acceptable situation,
as the backlog of “urgent” and “soon”
patients will contain many who have been
waiting unacceptably long periods, and it
is necessary to sort out the backlog in
these categories. In terms of meeting
waiting times targets, this process will
unfortunately mean that as no patients
are being taken from the end of the
routine patients, maximum waiting times
will increase during this initial period.
To avoid this happening, some Trusts are
using a modification of the PTL so that a
small number of slots are allocated solely
to routine patients, who are taken from
the top of the routine part of the list.
This goes against the intent of the PTL,
but will minimise the increase in waiting
times in the short term, and may be a
necessary compromise while the backlog
is cleared.
Inpatient PTLs
Inpatient and Daycase lists should be
managed as primary targeting lists in the
same way as outpatient and diagnostic
lists. The removal from the list should
remain strictly according to list order.
Temptations to pick specific conditions to
balance theatre time requirements is a
constant problem in inpatient lists.
There are two ways of managing this.
Where possible, patients should be picked
strictly in order from the primary targeting
list for pre-operative assessment clinics,
and then allocated to surgical lists from
those pre-operative clinics (this is
described in more detail in chapter 3).
Where this is not yet in place, patients
should be picked from a band at the top
of the PTL, and the make-up of those
within the band of patients monitored
A guide to good practice
Monitoring outpatients
Gwent Healthcare NHS Trust
Measures were required to provide
information about the performance of
waiting lists. It was important to gather
enough information on a regular basis to
assess how modernisation strategies and
capacity were affecting lists.
A number of measures were developed and
were provided centrally to directorates.
They are distributed monthly to
Directorates.
The measures include:
1. Booked activity against template (to
monitor under and over activity)
2. New to follow-up ratio and breakdown
of priority (changes)
3. DNA rates by priority (monitor
reductions and increase)
4. Cancellation rates
5. Average waiting times per Consultant
and site (shows variation)
6. Waiting times by waiting band — by
month (shows variation and reduction
of ‘tail’)
7. Primary target rates (selection of
patients from the back)
8. Primary target list score (selection of
patients from the back)
9. Total list scores (change in waiting
times measured in days not patients)
10. Referrals
11. Rate of partial booking
The measures and results have generated
interest and development in three areas.
1 Pooling across Gwent — Variance in
average waiting times and poor primary
target rates have generated interest in
pooling as a means of improving waiting
times.
2 Tidying up data — common problems
include erroneous prioritising of
patients and multiple referrals.
3 Increased understanding of template
variance – this has encouraged closer
monitoring.
Page 35
2.4 Primary targeting lists
closely to ensure that no patient remains
within the band for any length of time.
This allows surgeons a “restricted
flexibility” around who they choose for
surgery.
Where there has been a practice of picking
from well down the list to fill surgical lists
(e.g. day case patients in orthopaedics)
the problem is not one of managing the
PTL, it is instead a problem of imbalance
in the provision of inpatient and day case
lists. In this situation, adjusting the
balance of daycase work to inpatient
work, or moving more work onto the
daycase list, is preferable to maintaining
unequal waiting times.
Prioritisation of inpatient PTLs
Unlike the outpatient PTLs, there may be
a need to prioritise patients more
carefully on inpatient lists. The coarse
prioritisation into “urgent, soon and
routine” may not be adequate for
inpatient lists that are very long. There
may be patients who are not “soon” but
cannot wait as long as the most “routine”
case.
Additional levels of prioritisation are
acceptable in this case, but should be used
with care. As has been described in the
prioritisation section, the more levels of
prioritisation used, the longer the waiting
times will be for the most “routine” cases.
Where there is a greater
flow onto the waiting list
than off it (and
Targeting services
Bro Morgannwg NHS Trust consequently the list is
getting longer) high
The Problem
During pregnancy, there is a client group who due to substance degrees of prioritisation
misuse problems such as alcohol or hard drugs have many will ensure that some
health problems for themselves but more importantly their patients at the back of
baby. This client group very often fail to attend for antenatal the list never receive
care, become high-risk pregnancies with low birth weight surgery — and certainly
babies. There are very often complex social conditions and not within the target
possible child protection implications.
times set by the
Assembly.
The Solution
In an attempt to provide targeted and specialised antenatal
services to this vulnerable client group, Bro Morgannwg NHS
Trust has implemented a Substance Misuse Clinic. This
antenatal clinic is run weekly in conjunction with:
•
Substance misuse specialist midwife
•
Specialist Obstetrician
•
Community Drug and Alcohol Team
The women are able to receive antenatal care and advice,
support and medical treatment to either control or address
their substance misuse problem.
Monitoring primary
targeting lists
The use of primary
targeting lists is erratic,
even in Trusts where their
use is policy. The
development of a good
monitoring tool that both
ensures the use of PTLs
and shows their impact
on waiting lists, is
essential.
Result
The Clinic has been successfully run for the past year. It has
resulted in a reduction of the failure to attend rate amongst
this group of clients. A number of women have reduced their
drug intake or stopped altogether. There has been less effect
on the baby and fewer admissions to the Special Care Baby
Unit.
Page 36
A guide to good practice
2.4 Primary targeting lists
Measuring primary targeting
Gwent Healthcare NHS Trust
Gwent Healthcare has developed measures to monitor the effectiveness of management
of routine waiting lists by each directorate. It does this by determining the rate at which
patients are taken from the back of the waiting list (ie in order of their waiting time).
There are 2 measures: Primary target rate and primary target list score.
Primary target rate (PTR):
This is used to calculate the number of
patients who were booked beyond the
primary target date (ie the shortest waiting
list date if routine patients were seen in
strict order from the back of the list).
Changes to how waiting lists are managed
are envisaged due to information gained
from primary targeting.
For one speciality at Gwent in January 2003
the primary target rates were 53% at site 1
and 46% at site 2, but overall primary target
rate was only 28% due to the inequality in
waiting times at the two sites.
Number of routine patients seen in the
month with a date on list before the
primary target date
PTR =
Total number of routine patients seen
in the month
For same service if we look at their primary
target list score:
Site 1 PTLS = 73%
Site 2 PTLS = 72%
Overall PTLS = 50%
Primary Target List Score (PTLS):
Provides assessment of how many days could
have been “saved or removed” from the
waiting list if a 100% PTR had been achieved
whilst taking into account the effect that
booking patients from the middle or
beginning of the waiting list has.
Even if both sites were at 100% (ie selecting
routine patients to be seen strictly from
the back of each list), the overall primary
target rates and lists scores would not be
high due to a 7 month primary target date
difference between the two sites.
The total number of days accrued
on waiting list by the routine patients
seen in the month
PTLS =
The maximum number of days
accrued that could have been
removed through seeing the long
wait patients (achieving 100% PTR)
Monitoring primary target rates and lists
scores over time can monitor changes in the
way lists are managed.
Changes in Primary Target Rates and Lists scores over time
80%
70%
60%
% seen
50%
40%
30%
20%
Monitoring started here
10%
0%
Jan-03
Feb-03
Mar-03
Apr-03
May-03
Jun-03
Jul-03
Aug-03
Sep-03
Month
Primary Target Rate
A guide to good practice
Primary Target List score
Page 37
2.4 Primary targeting lists
Nurse practitioner ENT
Conwy & Denbighshire NHS Trust
100
90
80
70
60
50
40
30
20
10
0
AUDIOLOGY
HZ
ZH
300
250
200
150
100
SE
PT
AU
G
E
LY
JU
JU
N
M
AY
The role has been structured to reduce the
workload of junior doctors, and improve the
waiting times for outpatient clinics and the
quality of the patient experience. It also
helps to provide continuity of care for the
patient, and allows professional
development of nursing staff.
C
H
JEO
JA
N
Referral protocols developed by the Nurse
Practitioner include the following:·
Telephone clinic
·
Thyroidectomy Pop care
·
Laryngectomy Care
·
Skin tests
·
Hearing aid Clinic (new patients)
·
Dressings
·
Routine suction clearance
·
Audiology
A greatly improved service for Audiology
patients in the Hearing Aid Clinics has
resulted from the introduction of the nurse
practitioner role, and since January the
number of new patients seen in the Hearing
Aid Clinics has increased steadily, resulting
in a reduction of the waiting time from 9
months in January 03 to the current waiting
time of 5 months.
M
AR
Nurse practitioner for ENT is a development
post, which has been funded for 12 months
by Innovations in Care. Nurse-led Outpatient
Clinics are now held to support our three
ENT consultants.
Number of patients referred since January
to September 03 from Audiology and 3 ENT
consultants.
The Nurse Practitioner role is a valuable
asset to the department, and continual
improvements are being made to the various
services offered to patients, such as
telephone clinics for appropriate patients,
which means continuing reduction in review
outpatient attendances, and the resulting
increase in clinic capacity for consultant
clinics.
50
0
JAN
MARCH
MAY
JUNE
JULY
AUG
SEPT
Overall Number of patients referred from
Jan-Sep 2003
Page 38
A guide to good practice
Chapter 3
Patient focussed
booking
Booking is integral to improvement in the NHS in Wales. This section will
look at a number of different aspects of booking, dealing with the full
range of inpatient and outpatient events. The total approach to booking
is referred to as Patient focussed booking, and this phrase should be used
whenever possible. Above all, avoid use of the phrase “partial booking”
when communicating with the public.
Why patient focussed booking?
Patient focussed booking: A
The Innovations in Care Team recommends combination of full booking,
that all appointments between patients direct booking and partial booking
and Trusts be made by agreement. In some Full booking
cases this means that appointments are In England, policy requires that Trusts
made while the patient is present (for move towards a policy of full booking. The
example some follow-up outpatient key principle for full booking is that the
appointments)
patient always leaves
while in other
appointment
Good Practice Point an
cases it means
knowing the exact
Patient Focussed Booking
that appointments
date and time of
All appointments where the patient
are made by
their next attenattends
the
Trust
should
be
booked.
The
telephone.
In
dance at the Trust. In
key requirements of patient focussed
some cases it will
fact, this is common
booking
are
that
the
patient
is
directly
mean that an
for
follow-up
appointment with involved in negotiating the appointment appointments in most
another health date and time, and that no appointment Trusts now.
is made more than six weeks into the
provider is made
future.
at a previous
Full booking requires
appointment — for
a date to be negotiated with the patient
example, a secondary care outpatient no matter how far into the future an
appointment may be made while the appointment will be. If the waiting list
patient is at their GP.
for a particular surgical priority is nine
months, then under a full booking system,
a date for surgery must be agreed for nine
months into the future.
A guide to good practice
Page 39
3.0 Patient focussed booking
With a six week policy for leave it is not
possible to give the patient a reasonable
assurance that the Trust will not have
to cancel an appointment made several
months into the future.
Partial booking
Partial booking has been included as part
of patient focussed booking by Innovations
in Care because it enhances patient
choice, ensures clinic and theatre
efficiency by reducing non-attendances
and cancellations, and improves
communication between the Trust and the
public.
Partial booking differs from full booking
in one key respect: no appointment is ever
made more than six weeks into the future.
With a six week agreed leave policy, the
need to cancel appointments or surgical
dates is significantly reduced. It is possible
to give a strong assurance that an agreed
appointment will be honoured by the
Trust.
Direct booking
Direct booking has been a major focus of
booking in England. Electronic booking is
a key to the English implementation of
direct booking.
Direct booking involves GPs having access
to Trust appointment systems so that they
are able to book appointments within the
Trust from their surgery while the patient
is present. In Wales, direct booking is
recommended as part of patient focussed
booking, as long as the appointment being
booked is no more than six weeks into the
future. Innovations in Care does not
recommend direct booking more than six
weeks into the future.
Nurse practitioner
ophthalmic service
Conwy & Denbighshire NHS Trust
The needs of the ophthalmic patient have
dramatically changed over the past decade.
Changes and advances in computer and
surgical technology, lasers, drug therapies,
digital imaging and so forth have changed
ophthalmic practice unrecognisably and the
delivery of ophthalmic services has changed
to address these demands. Technological
advances have increased public expectation
of patient and health service provision.
Waiting is no longer an acceptable option,
and this concept is supported by the Health
& Social Care guide for Wales document
(2002).
The development of the Nurse Practitioner
role has evolved to include management of
nurse-led glaucoma clinics and postoperative cataract clinics. Safe practice is
assured through competency-based training,
clinical supervision, mentorship and an
induction programme. An advanced
educational module for nurse practitioners
is also available in North Wales and coordinated locally at H. M. Stanley hospital
in St. Asaph. All practitioners adhere to
agreed clinical pathways of recognised
practice, with documentation and patient
outcomes regularly monitored through
audit. In addition to nurse-led clinics the
practitioner team is responsible for diabetic
retinopathy screening in the local
community and the assessment and
treatment of specified ophthalmic
casualties.
Practitioners have played a vital role in
assisting the Directorate to meet annual
targets for referral waiting times, casualty
services and nurse-led services. Feedback
is gathered formally from service users in
the form of user surveys, which provide
feedback and favorable support for
practitioner input.
Electronic booking, as an enabler of direct
booking for urgent appointments, is part
of the Informing Healthcare strategy.
Page 40
A guide to good practice
3.1 Involving patients
Involving patients
The NHS exists for the benefit of the patient, and the vast majority of
staff within the NHS strive daily to improve the life of their patients. Yet
the role of the patient in health care is changing. Increasing demands for
information, and for the right to be involved in the design of services, has
led to a significant challenge for an NHS that has traditionally been seen
as paternalistic. The NHS must involve patients in all levels of their care,
and in the redesign of patient services.
Involving the patient in redesign
Too often in the NHS, patient surveys have
There are many ways to involve the been used to “pat ourselves on the back”.
patient in redesign of patient service, and The purpose of surveys should not be to
these fall into two main groups: patient find out if the Trust is doing a good job;
involvement, and soliciting patient views. they should be explicitly aimed at finding
In both cases, there is a fundamental out what can be improved. There are a
position that must be observed. It is the number of tools to help in this process.
patient’s right to be involved in their
health care, and this right should extend
Written Surveys
to the design of the
Good Practice Point The easiest way to
method by which
gain information is
that
care
is
Patient Involvement
through the patient
delivered.
Any Patients should be involved at all levels survey, and this
involvement must
of the improvement process. Patients
often elicits the
not be token. It
should be represented on all project
least information.
must be sincere and
teams, and patient views sought on
However patient
it must be followed
proposed solutions.
surveys do have a
through. There is no
place.
Regular
point in inviting
surveys of patients
patients to sit on redesign teams if their can be used as a quick and easy way of
views are not listened to. There is no point keeping a watch on the state of the
in undertaking patient surveys if there is service, and results collated over time can
no follow-through into action in improving show up trends.
those services.
Soliciting the views of patients
Do the patients like the service? Phone or
mail surveys, interviews in clinic etc, are
valuable to determine what parts of the
system still need improving. Patient
comments are essential to tailoring the
service to their needs.
A guide to good practice
When designing the survey, it is important
to ask first “Why?” The purpose of the
survey will help frame the questions, and
will affect the method of analysis. Then
ask “How will we analyse this survey?” Too
often survey forms are designed
backwards; a form is created
Page 41
3.1 Involving patients
(incorporating all the questions anyone
may ever want to know the answer to),
circulated and collected. Then someone
is asked “How do we analyse this
information?”
The design of patient surveys should go
through the following sequence of
questions:
1 What question is being answered by this
survey?
2 What information is needed to answer
the question?
3 How will the information be presented
once it has been analysed?
4 What sort of analysis will be necessary
to allow this form of presentation?
5 What data must be collected, in what
format, to allow that analysis to be
done?
6 How will the data be collected?
This design process is the reverse of the
process the actual data will follow — start
at the end point to ensure that everything
is in place to allow the process to be
completed.
Surveys should be used to monitor
positions over time, using graphical output
to show trends. They can also be used to
solicit a wide number of views quickly.
Tick box surveys are quicker to complete
and analyse, but solicit a poorer quality
of information. Open questions such as
“please tell us of any problems you
experienced at the reception desk” will
give more information than check boxes
or questions that elicit a “Yes/No” answer,
but they are harder to design and analyse,
and more of a burden for the patient to
complete. You should take into account
the burden of completing the form, if for
no other reason than that you will get
Page 42
better results if the survey is easy and
quick to complete.
Most people are not professional survey
compilers. When in doubt, talk to your
audit department about survey design.
Patient focus groups
Focus groups can also be useful in
providing regular feedback on services and
in identifying areas that need
improvement. Where focus groups are
being contemplated, trained facilitators
should be consulted and used in designing
and running the groups. Questions to be
covered by the group should be clear, and
time must be given to allow those involved
to raise other issues that may concern
them. Above all, the focus group should
be seen as belonging to the patients, and
not to the facilitator or Trust.
Patient diaries
A powerful but time-consuming tool is the
use of a patient diary. Asking a patient to
record their thoughts and feelings about
their care as they pass through the process
can be valuable but will be a significant
burden on the patient at a time when they
may be experiencing stress and
vulnerability. Patients must have the
process explained to them clearly, be
given a choice of written or recorded
diaries, and above all it must be clear that
they can opt out of the process at any
time.
Patient diaries have given greater impetus
to change service delivery than any other
tool.
Patient walk through
An alternative to the diary, for shorter
patient care processes, is the patient walk
through. This is typically used as an aid
to process mapping, giving a clear view
of the process from the patient point of
view.
A guide to good practice
3.1 Involving patients
The process involves a member of the
improvement team shadowing a patient
from the time they arrive at the front of
the hospital, to the time that they leave
the premises. Everything that happens is
recorded using the process mapping
approach of “one person, one place, one
time”.
If privacy concerns are met, a valuable
aid to the walk through is a camera, so
that a photographic record of the patient
journey can be compiled. This, coupled
with a diary from the patient, can give a
more complete understanding of the
patient process than any other tool.
Who should do the walk through? Some
Trusts have found non-executive directors
to be particularly interested in this tool.
As well as giving them a better
understanding of the processes within the
Trust, it will give valuable insight when
the improvement projects require Board
level decisions.
Patient involvement in change
All the tools above are about finding out
the views of the patients about their care.
Far more difficult, and challenging for
redesign projects, is involving patients in
the redesign process itself.
If the NHS is to provide a patient focussed
service, patients must be involved at all
levels of the organisation. This includes
improvement programmes, project
boards, Innovations in Care Boards, and
redesign teams. The question when
selecting membership for any board or
team should not be “Do we need a
patient?” but rather “Is there any valid
reason to exclude patients from this
process?” The answer to the question
should nearly always be “No”.
Patient involvement should not be token.
In some cases a single patient may be
enough; in many cases, at least two
A guide to good practice
patients will ensure that the patients are
not isolated within the group.
Patient involvement in the group should
not be confused with patient
representative involvement. Organisations such as Community Health Councils
should be represented on many groups,
but CHC involvement is not the same as
patient involvement. The purpose of
patient involvement is not to ask that
person to represent patients, but rather
to represent themselves — to offer views
from their perspective as an outsider who
has to interact with the hospital.
Finding patients
How do you identify patients for these
activities? There are a several sources.
• Notices in hospital waiting areas asking
for people who would be interested in
giving up some time to be involved.
• Postcards in waiting areas that explain
the patient involvement process.
Patients complete the card if they are
interested in being part of a pool of
patients who will be canvassed from
time to time.
• Complaint letters. These are written
by people who have views on the
quality of service and will often be
prepared to participate in programmes
to improve services.
Staff are not patients. Avoid the easy
option of saying that “all staff are
potential patients”. Staff who are patients
can offer valuable insights into problems
with services, but they are not
independent. They will always carry their
perspective from working in the NHS,
which will filter their perception of
service delivery, and will rarely lead to
the same insights as an independent
patient.
Page 43
3.1 Involving patients
Copying letters to patients
One area where all organisations in the
NHS can improve the involvement of
patients is by copying letters to patients.
Enabling patients to receive a copy of
letters written about them by one
professional to another should be seen as
an essential part of good clinical care. It
should improve communication between
patients and healthcare professionals, and
also improve the patient’s ability to
understand and make choices about their
own care and treatment.
This practice is policy in England, and
the Welsh Assembly Government is
currently undertaking a scoping exercise
to determine what form the initiative will
take in Wales. Much of the good practice
described here is based on the English
policy and experience.
patients on their first, and preferably
subsequent visits. As a first step, and a
minimum standard, patients must be
informed of their right to receive copies
of all letters, and supported in their
requests to receive such copies.
What letters should be copied?
All letters between two health
professionals should be included in the
copying process. This includes referral
letters from GPs to the trust, letters from
clinical staff to the GP, and letters from
clinical staff to each other. It should also
include letters to outside agencies such
as Social Services.
Single results, such as laboratory reports,
or x-ray reports, should not be copied.
The information in these reports is likely
to be included in subsequent letters in
many cases, and there is consequently no
need to copy the raw data to the patient.
Why copy letters to patients?
Overwhelmingly,
Who should
surveys of patients
Good Practice Point receive letters?
and carers show
Letters should be
Copying Letters to Patients
that they want to
copied to the
All
communications
between
health
see copies of letters
patient and their
professionals should be copied to the
about their care.
carer
where
patient.
Patients
must
be
given
the
Evidence
is
appropriate. The
right to opt out of receiving letters.
available
from
patient must retain
Good
practice
is
to
write
all
letters
to
England, and some
the right to receive
departments in the patient, and copy the letter to the a copy of their
other health professional.
Welsh Trusts, that
letter, but not have
copying information
it copied to the
to patients reduces errors, improves carer, if they wish. In the case of children,
communication, and leads to better the letter would go to the carer in most
standards of care*. There is little evidence circumstances.
that patients do not want to see this
information.
There will be explicit situations when it
Copying letters should be the default
policy of all NHS organisations, with a
clear “opt out” option explained to
* Copying letters to patients: Summaries of 12
pilot project sites. Health Organisations
Research Centre, Manchester School of
Management 2003
Page 44
is not appropriate to copy a letter to the
patient. Two examples are when the letter
contains information about a third party,
or when the clinician considers that the
letter would be harmful to the patient.
In the second situation, the clinician has
a responsibility to explain to the patient
the reasons why the letter is not sent.
A guide to good practice
3.1 Involving patients
In general, care should be
taken to avoid patients
learning about bad news
by letter, and where a
letter contains bad news
the patient should
receive the letter in an
environment where the
contents
can
be
explained before the
letter is read.
Questions of Jargon
It is often assumed by
clinical staff that
patients do not need or
desire to see letters. As
has been stated, the
evidence is that the
patient view is very
different.
Another
common clinician view is
that the patient would
not understand the letter
if it was sent.
There is some anecdotal
evidence to support this
belief, although where
letters are currently
sent, the patients
surveyed showed a
greater level of understanding than the
clinicians had assumed.
The solution is to present
information in a clear
format, avoid the use of
jargon, and be explicit in
statements made.
There are ways of
demystifying letters
through the use of
substitution (using nonjargon words wherever
possible), providing
explanations for medical
terms in an annex to the
letter, or by providing a
A guide to good practice
Copying letters to patients
Cardiff and Vale NHS Trust
The Wales Epilepsy Unit at the University Hospital of Wales
routinely copies all letters to patients unless there are specific
reasons to do otherwise. Diagnoses, management plans,
medication and lifestyle advice are also communicated and
can thus be read and reread away from the stress and
distraction of the clinical environment.
Swansea NHS Trust
The diabetic and lipid clinic at Morriston Hospital copies all
letters to patients routinely. Staff consider this process to
be essential as a supplement to the advice given verbally to
the patient in clinic. Letters also include the results of blood
tests and explanations of what the results mean.
The consultant in plastic surgery at Morriston Hospital issues
letters directly to patients who have had an augmentation
procedure. This is because the consultant feels that some
patients may not fully understand what is being said to them
in clinic.
In community paediatric services, there is limited routine
copying of letters to the parent/guardian relating specifically
to the Development Co-ordination Disorder clinic.
Velindre NHS Trust
Cervical Screening Wales and Breast Test Wales send results
of mammography and cytology directly to women. In addition
to this, for the more complex assessments in CSW less
technical letters are sent to patients.
Conwy & Denbighshire NHS Trust
In the paediatric allergy clinic, the consultant copies letters
to patients as a matter of routine.
North Glamorgan NHS Trust
One paediatrician issues copy letters as standard practice
and has done so for a number of years. Another takes the
view that letters should be copied selectively. In these cases,
the letter is addressed to the patient and copied to the GP.
The Head Psychologist (appointed from an English Trust) has
continued the policy of copying correspondence to patients.
He has had considerable practical experience of the
advantages and disadvantages of letter sharing, and takes
the view that the advantages of copying letters outweigh
the disadvantages. He comments:
“… Greater openness and copying all correspondence is in line with
a more patient-centred philosophy in which more active participation
and dialogue is encouraged rather than merely passive compliance
with “expert” pronouncements and prescriptions. To this end,
patients appreciate being kept well informed and clinicians are
challenged to use simple language, and certainly to refrain from
being pejorative.”
Page 45
3.1 Involving patients
help line for patients who have difficulty
understanding the letters.
towards a more open and patient centred
health service.
A good practice is to write all letters to
the patient, and copy the letter to the
health professional. This practice, already
used by some health professionals, leads
to clearer communication and an
improvement in the doctor patient
relationship.
Developments in England
Good practice guidelines “Copying Letters
to Patients” have been issued in England
to assist NHS organisations in putting the
policy into practice. These guidelines have
been informed by the results of pilot
studies, which aimed to test key aspects
of issues relating to implementation.
Copies of the guidelines can be obtained
from the website:
Translation
In some situations, letters may need to
be translated before being sent to
patients. Translation can be problematical
when technical terms are used.
Experience in England has shown that
many patients would be happy to receive
their letter copies in English even where
this is not their first language. Where
translation is desirable, formatting the
letter in such a way that the key points
are at the start of the letter and outcomes
and actions are at the end, then only
translating the key points and summary,
is a reasonable compromise.
www.doh.gov.uk/patientletters/issues.htm
The way forward in Wales
Close links have been established with the
initiative in England. In Wales a number
of pilot studies are being considered in
order to test implementation on an
organisation wide basis such as a hospital
or GP practice. The results of these studies
and further developments in England will
be used to inform how the copying letters
initiative will be taken forward in Wales.
Where possible, patients should be able
to request translations of letters as well
as large print versions.
Conclusions
The process of moving towards all patients
who want copies receiving them will be a
difficult one. There are IT and cost
implications, although these may
ultimately not prove to be as significant
as they may seem at first glance. However,
there is no doubt that informed patients
are better able to participate in their own
care. They are likely to pick up on
mistakes and errors that they find in
letters thus reducing risk. Above all,
patients want to see this information.
Twenty years ago patients were not able
to see their own medical records. That
situation has now changed, and copying
letters to patients is the logical next step
Page 46
A guide to good practice
3.2 Generic referrals and pooling
Generic referrals
and pooling
Traditionally in the NHS, referrals have been made from a GP to a named
consultant. Patients seeing a specific consultant have been placed on
that consultant’s waiting list. Patients seen in one location are followed
up in the same location. Patients seen on one site will have their diagnostic
procedures performed on that site. Patients will be seen in specialist or
subspecialist clinics. All of these factors increase waiting times, and all
can be addressed through generic referrals and pooling.
What are waiting lists?
Staff tend to think of waiting lists as an
indication of a shortage of resources, but
resource shortage is not the only reason
waiting lists develop. Waiting lists are
simply queues, and a lot can be learnt
about managing waiting lists from how
other organisations manage queues.
section. Rather than each consultant
having a single outpatient waiting list,
there should be a single list for the
speciality. Rather than multiple inpatient
waiting lists, each surgeon should pick
from the top of a single list. Eventually,
outpatient and inpatient lists should be
managed as a single process on a single
list. This is the same as having a single
queue in a bank, and the customer going
to the next available window.
Understanding queues
Queuing theory is a well developed
science in mathematics, and fortunately
one does not need to understand it in Problems with pooling
depth in order to make progress on Unfortunately, waiting lists are not bank
managing waiting
queues. There are
Good
Practice
Point
lists. The one thing
multiple priorities
it is important to
within waiting lists,
Generic
Referrals
and
Pooling
know is that a
and there are
Referrals into Trusts should be pooled
single queue in
multiple
subwithin
specialities.
Referrals
to
a
front of multiple
specialities within a
“windows” will specific consultant by a GP should only speciality. Multiple
be accepted when there are specific
have
shorter
priorities within a
overall waiting clinical requirements, or stated patient list are easily
preference.
times than a series
managed through
of short queues in
the use of PTLs, as
front of each window. This is the “Post illustrated in chapter 2. Management of
Office” queue, seen in most commercial subspecialisation is more of a problem,
premises apart from supermarkets.
but it is one that must be resolved. There
are three possible solutions.
The basic unit of the queue is the primary
targeting list described in the previous
A guide to good practice
Page 47
3.2 Generic referrals and pooling
In this method, separate lists are
maintained on the IT system, one for each
subspeciality and one for the generic
patients. Patients are added to the
bottom of each list.
2
2
3
3
5
4
6
6
7
8
8
9
Figure 8b. Step 2: Combine the lists
When the lists are displayed, it is
important not to distinguish on screen
between the generic patients and the
subspeciality patients. Each consultant
will see a single waiting list of their own
patients merged with the generic
patients, with no visible distinction
between the generic and the subspeciality
patients.
1
2
2
3
3
5
4
6
4
7
3
6
7
6
8
8
8
9
Consultant B
Consultant A
Figure 8a. Step 1: Three different lists
Consultant B
2
Consultant A
5
Generic List
1
9
Page 48
1
Consultant B
“Hidden” pooled lists
A solution to this problem can be to “hide”
which patients are on generic lists and
which are on the subspeciality lists. This
solution is the best option where it can
be implemented electronically, or where
waiting lists are maintained centrally. It
is harder to maintain where each surgeon
or their secretary maintains the list.
When the lists are displayed, the
subspeciality lists are merged with the
generic list in referral date order. Patients
from the generic list (the white numbers
in the example) are shown on each list.
The patients have not been added to both
lists — they still exist on a third actual
list, so they are not duplicated although
they appear to be. They are simply shown
in the new “virtual” lists as demonstrated
in figure 8b.
Consultant A
Maintenance of a “pooled” list
The simplest solution to the problem of
pooling in subspecialities is to maintain a
generic pooled list in addition to each
consultant’s own subspeciality list. All
patients who need to be seen within a
subspeciality are added to the individual
consultant list, while those able to be seen
by any consultant are added to the pooled
list. The main problem with this approach
is ensuring that the pooled list is treated
at the same level of priority as the
individual lists. In most situations where
this approach has been used, consultants
exhibit a tendency to remove patients
from their own subspeciality list ahead of
those from the pooled list. In some cases
it has been found that patients are added
to a pooled list and no-one removes them.
Figure 8c. Step 3: The consultant view
A guide to good practice
3.2 Generic referrals and pooling
The reason that this method works best
when implemented electronically or
through a centralised waiting list
management team is that otherwise there
is the possibility for a patient to be picked
from the list by more than one consultant.
In an electronic system using virtual lists,
record locking protocols will prevent
multiple picking, while in a centralised
environment management procedures can
be put in place to have the same effect.
patients. There must be no blank rows on
the matrix.
Ensure that all
conditions have at least
one consultant
Condition 1
X
X
X
X
Condition 2
Condition 3
X X
Condition 4
Condition 5
X
Condition 2
X
Cons FF
Cons EE
Cons FF
Condition 5
Cons DD
X X X
X X X X X X
Cons AA
Condition 4
CCG 1
X X
Cons EE
Condition 3
Condition 6
Condition 3
X
X X X
X
Cons DD
Condition 1
Condition 5
Condition 2
Cons CC
Each row of the matrix can now be
considered as a “clinical care group”, that
is a group of patients who can be managed
by a specific group of clinicians. In some
cases, a condition may only be within one
clinical care group. Some consultants may
appear in several clinical care groups with
different colleagues:
Condition 4
Condition 1
Cons BB
Cons AA
Figure 9b. Step 2: Fill in the matrix
Cons CC
The first step in this approach is to sit
down with the clinical staff in the
speciality and list all the conditions on
the waiting list, and all the staff available
to see or treat those patients. A matrix is
then constructed as follows:
X X X X X X
Condition 6
Cons BB
The Matrix approach
What if it is not possible to implement a
generic list either electronically or
centrally? What about situations in large
Trusts where there may be multiple
consultants in each subspeciality, making
the implementation of the “Hidden Pooled
List” more complex? A number of Trusts
use an approach of adding each new
referral to the shortest waiting list, using
a matrix to determine which waiting lists
are available.
Cons FF
Cons EE
Cons DD
Cons CC
Cons BB
Cons AA
Condition 6
Figure 9a. Step 1: Create the matrix
Then, with the involvement of the clinical
staff, each cell of the matrix is filled in
so that every condition has at least one
consultant marked. Where there is not a
consultant, it must be determined who is
available to see those patients, or what
the Trust policy is for managing those
A guide to good practice
Figure 9c. Step 3: Identify the Clinical Care
Group
Each consultant will have their own
entirely unique waiting list. The patient
is added to the shortest waiting list within
the clinical care group. In the example in
figure 9d, a patient with condition 3 will
be added to Consultant AA’s list, because
that is the shortest waiting list out of AA
and DD, the only two waiting lists in the
matrix for condition 3.
Page 49
3.2 Generic referrals and pooling
and a new consultant starts work. By
definition, that consultant will have the
shortest wait (under 12 months) for the
first year, and potentially all patients
referred in that year will be added to that
list — leading to an inflated list for one
consultant which may take some time to
clear.
Patient with
condition 3
Cons FF
Cons EE
Cons DD
Cons CC
Cons BB
Cons AA
CCG 3
Figure 9d. Step 4: Select the shortest list
What do we mean by shortest?
There are many definitions of “shortest”
when describing waiting lists. Each has
potential problems.
Clearance Time
A better definition, which is prospective
rather than retrospective, is clearance
time. This is calculated on the basis of
the number of patients on the waiting list
divided by the rate at which patients are
being removed. The clearance time in
weeks is the number of patients on the
list, divided by the number expected to
be removed each week. In effect, this is
the time that it would take to clear the
list if no new patients were to be added,
or the time that a patient added today
could be expected to wait.
Fewest patients on the waiting list
This definition does not take into account
the rate at which patients are removed —
a
consultant
who
operates on a lot of
Pooled waiting lists in Cardiology
complex cases will take
Cardiff and Vale NHS Trust
patients off the waiting
This
initiative
was
taken
in
response
to the need to address
list at a slower rate. A
consultant who has many differential and unacceptably long waiting times for
outpatient clinics will cardiology outpatients referred to the Trust’s 6 consultant
cardiologists.
remove
outpatient
referrals at a faster rate A detailed consultant-led review was undertaken to determine
than one who has few how this situation could be addressed. This resulted in a plan
clinics.
to pool all referrals for agreed conditions. Waiting lists for
Shortest Wait
The consultant with the
shortest
maximum
waiting time may seem a
sensible definition of
shortest, but it is defining
shortest future wait on
the basis of shortest
historical wait, and will
not take account of
changes in circumstances. This will be most
clearly seen in cases
where most consultants
have a wait of 12 months,
Page 50
both Trust sites were merged, and booking templates agreed
for all clinics so that the same number of patients is planned
for each. A protocol was agreed with consultants for assigning
referrals to subspeciality clinics only on an exception basis,
with all others being considered as suitable for the pool. In
each consultant clinic, a certain number of slots are set aside
for subspeciality patients, with the remainder of the slots
being used for patients from the pool. The consultant who
sees the patient at their first appointment undertakes any
subsequent follow-up. The system was designed to be
compatible with partial booking.
The new system achieved a reduction in numbers of patients
waiting over 18 months between January and March 2003
from 188 to just 13, and this figure has since been further
reduced. At the end of September, a maximum waiting time
of 15 months has been achieved.
A guide to good practice
3.2 Generic referrals and pooling
Clearance time will only be accurate as
long as circumstances do not change, but
will be adjusted automatically if
circumstances do change. It does take
some account of casemix on the list, as
casemix will affect removal rates.
Counting on the basis of casemix would
be even more accurate however.
time for the condition to each patient on
the list, so that the clearance time can
be calculated in theatre minutes. This will
be far more accurate than any measure
that works on patient numbers.
Who owns the pooled list?
There is one final question: who has
clinical responsibility for a pooled or
generic list? It is a requirement of the
Counting casemix rather than patients
Chapter 4 points out the danger of Assembly that every patient waiting for
counting work as patients or Finished either inpatient treatment or on an
Consultant Episodes (FCEs). When outpatient list is allocated to a specific
calculating clearance time, it would be consultant in terms of clinical
useful to allocate an expected theatre responsibility. Where a matrix approach
is used to allocate
patients to lists, generic
Caerphilly Back Pain Pathway
or pooled lists do not
Gwent Healthcare NHS Trust exist so this is not an
The Back Pain Pathway started on 1st October 2002 following issue. Where “hidden”
funding from Caerphilly Local Health Group. It offers GPs pooled lists are used, or
within Caerphilly Borough an acute access service for patients even the simple pooled
with low back pain. The team is headed by an Extended Scope lists mentioned first,
Practitioner (ESP) and senior physiotherapists, supported by there needs to be a
technical and administrative staff. Patients access the
named consultant for the
pathway via GP referrals made against set criteria and are
pooled list.
then paper triaged by the ESP, (usually within 48 hours of
referral).
Patients with complex conditions are assessed and treated
by the ESP or referred on appropriately to main stream
physiotherapy, a back education and lifestyle programme,
Pain clinic, or Radiology for further investigations as required.
There is direct access to an Orthopaedic Consultant should
any patient present with serious pathology or require a
surgical opinion.
This pathway offers a comprehensive integrated service to
GPs allowing patients with low back pain to be seen promptly
by the most appropriate practitioner at a location most
convenient to them.
Between 1st October 2002 and 31st August 2003 a total of 869
patients were referred to the Pathway. Of these, only 1 was
referred to the Orthopaedic Consultant and 1 was referred
to Radiology.
The pathway has improved quality of patient care, with 88%
of patients reporting satisfaction with the waiting time for
their first appointment, 75% showing an improvement in their
condition with physiotherapy and 96% of patients being
satisfied with their treatment location.
A guide to good practice
In most cases in Wales,
the Clinical Director of
the service has taken on
responsibility for the
pooled list and is
recorded as the named
consultant.
The
important thing to keep
in mind is that the named
consultant for a pooled
list has responsibility for
the patient while they
are waiting. Once the
patient has been booked
for surgery with a
consultant, they become
that
consultant’s
responsibility.
Page 51
3.2 Generic referrals and pooling
The impact of pooling
referrals could be seen by a GPSI rather
Pooling will have its biggest impact when than the consultant. This will reduce the
there are significant differences between cost per case, allowing greater volume
the length of waiting lists (either by through the system.
consultant or site). Where lists are
relatively even, the effect of pooling on
waiting times will be
minimal. However, the
Pooling in Pembrokeshire
use of pooling and
Pembrokeshire and Derwen NHS Trust
generic referrals is good The Problem
practice, and should be Surgical outpatient waiting lists had inequality between three
encouraged even when consultants — waiting times varying from two weeks to 13
the impact on waiting months.The consultants, who sub-specialize (ie breast,
lists would be minimal.
vascular and colo-rectal), would not accept a generic waiting
Why generic
referrals?
Generic referrals are
referrals sent to the
Trust, rather than a
named consultant. In
most cases, the referral
will be to a “Dear
Doctor”.
Generic
referrals are good practice. They recognise that
the Trust delivers a
service, not solely the
consultant, and they
allow the Trust and primary care to determine
how the service should
best be provided (either
pooled consultant lists,
or alternative practitioners).
Generic
referrals will promote
equity of access as
waiting times will be
based on the date
referred rather than the
consultant referred to.
Cost savings will be found
when the use of generic
referrals means that
patients can be seen by
staff other than a
consultant. For example
generic dermatology
Page 52
list for outpatients. Despite this, GPs often have very little
idea about ‘who does what’ in the hospital.
The Solution
1. Ask the consultant with the longest waiting times if he
would consider transferring any patients to the other
consultant’s lists. Ask the other consultants if they will
see the transferred patients.
2. Trawl through all of the longest waiting list with the
consultant to see who could be transferred.
3. Send letters to both the patients and their GPs asking if
they want to be transferred and thus be seen sooner, with
an option to stay with the original consultant if they so
wish.
4. Draw up a matrix of conditions and get each consultant to
acknowledge which he will see as an outpatient, and
subsequently as an inpatient or day case.
5. Inform the GPs of each consultant’s waiting times for first
outpatient appointments, day case surgery and inpatient
lists, together with the matrix of conditions. Inform the
GPs on a quarterly basis of the waiting times as above.
The Results
97 patients were deemed suitable by the consultant to be
transferred. The other consultants agreed to see them. Out
of the 97 only 13 patients were not transferred either at
their or their GPs request.
The 84 patients were all seen within six weeks.
The consultants supported the matrix and informing the GPs
of their individual waiting times. The matrix was only given
to the GPs at the beginning of August and so there are firm
numbers to report. However, on looking at the outpatient
waiting lists at the beginning of September it appears that
the two consultants with shorter waiting times have had more
referrals in August than the previous months. It will be easier
to establish whether it has had an impact after 3 months.
The Trust is hoping to introduce this method of keeping GPs
informed for all specialities in the future.
A guide to good practice
3.3 The booking process
The booking process
This section deals in detail with the booking process: how and why partial
booking works, how to apply it to returning outpatients as well as new
referrals, how patient focussed booking can be used to ensure that cancer
wait patients are seen within ten days, and how booking works with
inpatients and day cases.
Partial booking basics
Partial booking is an unfortunate phrase
that has become common currency within
Trusts, but which should be avoided when
communicating with patients. Innovations
in Care recommends the phrase Patient
Focussed Booking, which incorporates the
entire booking process. This document
defines partial booking as part of the
overall booking process.
Partial booking is not, in itself, a form of
booking. It is a way of managing the
waiting list to ensure that when booking
takes place, it is done with the direct
involvement of the patient. Partial
booking is a set of processes and
procedures to manage the waiting list
(such as the integration of primary
targeting lists into the PAS letter
generation process); a set of principles
around patient booking (such that no
appointment is made without the direct
involvement of the patient either by
phone or in person); and a set of practices,
such as the use of appointment centres
to provide a single and central point of
contact for patients within the Trust.
The relationship between partial and full
booking is shown on the diagram on page
54, but it can be reduced to a very simple
rule: if the appointment is going to occur
A guide to good practice
within the next six weeks, then full
booking should be used. If it is going to
be further than six weeks into the future,
then partial booking should be used.
Why patient focussed booking?
There are three main reasons for
abandoning the old system of
appointments. Patients are not seen in
order; patients do not have a choice of
date and time when receiving their
appointments; and a lot of time is spent
cancelling appointments. Patient focussed
booking addresses all of these issues.
Patients are seen in order
Patient focussed booking uses clinical
priority and time on the list to calculate
when a patient will be seen. This is a
considerable improvement on the
essentially random allocation of
appointments that has happened in the
past. The patients who need to be seen
within six weeks are booked directly into
appointment times through direct
booking. Patients who are not able to be
seen in six weeks are placed onto a list
which is sorted first by clinical priority
and then by waiting time. The sorting of
waiting lists is covered in more detail in
chapter 2, Primary targeting lists.
Page 53
3.3 The booking process
The Patient Focussed
Booking Process:
Overview
Patient needs an
appointment (either
first or follow-up)
Will the patient be seen
within 6 weeks?
No
Yes
Patient is placed on a
waiting list until the
appropriate time
Is electronic
access available?
Yes
No
Use direct
booking through
electronic access
Confirmation is
sent out by mail
Use direct
booking by
phoning the
Appointment
Centre
Patient is sent a
letter asking them to
phone the
Appointment Centre
and make a booking
Confirmation is
sent out by mail
Direct / Full
Booking
No
Does the patient
phone?
Partial
Booking
Yes
Reminder and removal
process
An appointment date
and time is agreed on
the phone
Confirmation is sent
out by mail
Figure 10. An overview of the booking process
Patients have a choice of appointment
date and time
Patient non-attendances and patient
cancellations consume a vast amount of
resource, as well as severely affecting the
flow of patients through clinic (as shown
in chapter 1). By agreeing a date and a
time with the patient, either face to face
in the case of direct booking or over the
phone in the case of partial booking, the
incidence of cancellations and DNAs
because the appointment is booked for a
date or time that the patient cannot
attend is considerably reduced.
Because the patient is arranging their
appointment at a time that suits them
approximately four weeks into the future,
they are far less likely to forget their
Page 54
appointment. This will further reduce
DNAs. DNA rates have dropped from 14%
to 3% in some clinics.
Hospital cancellations reduce
Because the Trust has a leave policy
requiring six weeks notification of any
leave that will affect an outpatient clinic,
and because the clinics are only filled
approximately four weeks before they
happen, clinics which are cancelled for
routine reasons (annual or study leave)
will be cancelled at a point when there
are no patients booked into them. No
patients need to be cancelled, and no rework is necessary. The few cancellations
at short notice (e.g. due to sickness) can
be rescheduled into an empty clinic in
five weeks time. Less re-work means more
A guide to good practice
3.3 The booking process
staff time available for other duties.
Partial Booking: New Referrals
over six weeks
The partial booking process is illustrated
in figure 11. The process acknowledges
the referral when it is received, and sends
letters to patients four weeks before they
need to attend, asking them to phone and
make an appointment.
3. The “Phone” letter
The “picked” patients are each sent a
letter, which asks them to phone the
Appointment Centre as soon as possible
to arrange a suitable date and time for
their appointment. When they phone, an
appointment is made on the PAS and a
confirmation letter is printed and sent.
4. What if not enough people phone?
The system is “self balancing”. If too few
patients phone in any week, extra letters
can be generated the following week.
Similarly, if more patients phone, bookings
can be made into week five, and
correspondingly fewer patients “picked”
the following week.
1. The acknowledgement letter
As a patient is registered and prioritised,
a letter is generated telling them the
approximate wait, and telling them to
expect another letter closer to the time.
An explanatory leaflet on the process is
enclosed with the first letter. A sample
letter can be found on
page 68.
Partial Booking Flow Chart
Referral received in Trust
If the patient is to be seen
within 6 weeks, they are
asked to phone straight
away and make an
appointment. These are
patients that should be
seen through the direct
booking process, but have
been referred in as a
lower priority or because
the GP does not want to
use the direct access
route.
Referral logged
To Consultant
for prioritisation
Yes
Within 6 weeks
No
Post letter advising
patient to phone
immediately
Acknowledgement letter generated
and sent out with information leaflet 1
Wait
Estimate empty slots available in
weeks 3 - 5
Generate Pick list letters
Check Letters and post with Leaflet 2
2. Generating the “Pick
List”
Every week, staff look at
clinics for four weeks
ahead. For each clinic
they calculate how many
patients will be needed to
fill the clinic, and select
those patients from the
top of a “pick list”. The
pick list is sorted first by
priority order, then
referral date order.
Yes
Patient Phones
No
Send Reminder Letter
Yes
Patient Phones
No
Send Close Down Letter
Yes
Patient Phones
Make Appointment in
weeks 1 or 3 to 5
No
Referral closed and letter filed
Patient attends
appointment
Figure 11. Partial booking flow diagram
A guide to good practice
Page 55
3.3 The booking process
5. What if the patient does not
phone?
A reminder letter is generated
automatically for those patients who do
not respond to the “phone” letter. If they
do not respond to this reminder within
two weeks, the referral is automatically
closed and a letter is sent to the GP as
well as the patient.
Partial booking: Follow-up
bookings over six weeks
There are considerable advantages to be
gained by applying the methodology to
follow-up outpatients as well as new
referrals. Cancellation and DNA rates are
usually higher for follow-up patients than
for new referrals. Clinics are frequently
overbooked with follow-up appointments
because these patients are perceived as
having a higher clinical priority than new
referrals. In specialities where “mixed”
clinics (containing both new and returning
patients) are common, all the benefits of
partial booking will not be seen until all
patients are booking using patient
focussed booking.
There are different issues involved in
partial booking for follow-up patients.
New routine referrals are seen on a “first
come, first served” basis within clinical
priority. With non-urgent follow-up
patients there is usually a clinically
significant time in which they should be
seen. We cannot see the two week
postoperative follow-up in 10 weeks, or
the 12 month review patient in six weeks.
For this reason, partial booking for followup patients is implemented in a slightly
different form. This involves a calculation
of priority when generating the pick list,
rather than a sort of the pick list on the
basis of assigned clinical priority and then
waiting time.
Some Trusts have tried prioritisation of
patients based on required appointment
date. This means that at the start of June,
the list will show patients due for
Page 56
appointments in July. This works where
there is adequate capacity for the service
— but if there are more requests for
appointments than there are available
appointment slots, then the patients will
be called later and later after the
requested time. If requested appointment
date is the sole prioritisation criterion,
limited appointment slots may not be
made available to those who need them
most. While some patients may be able
to wait two months from the requested
date, others may not. A patient who
should be seen in twelve months may
safely be able to wait fourteen months. A
patient due to be seen in two months may
not be able to wait four. If this system is
used, the monitoring process described on
page 97 is necessary.
Prioritising returning patients:
A solution
While no prioritisation system will resolve
a mismatch between capacity and
demand, where there is a mismatch it is
important to prioritise the patients to
make best use of the limited resources.
This suggested solution takes account of
the “flexibility” that may be present in
longer time period appointments.
1
Define the “Appointment Delay”
Two dates need to be provided: the
Request Date RD (when the appointment
was requested) and the Target Date TD
(when the appointment should occur).
2
Calculate the acceptable range
Two further dates are now determined:
calculate the delay TD - RD, then set the
Start Date SD (TD - 20% of the delay) and
the End Date ED (TD + 20% of the delay).
These two dates define the acceptable
range for the appointment. Note that
because a percentage is used, longer
interval appointments e.g. 12 months will
have a larger acceptable range than
shorter interval appointments e.g. three
months.
A guide to good practice
3.3 The booking process
3
Assign a priority
At the time the pick list is generated, a
priority must be assigned. This is
recalculated each time the pick list is
generated, because the priority is
determined by the relationship between
the clinic date CD (the date for which the
pick list is being generated — usually four
weeks into the future) and the dates
above.
Priority One
The Clinic Date (CD) is after the End Date
(ED). This means that the appointment is
already overdue, beyond the acceptable
range of possible appointments.
Priority Two
The Clinic Date (CD) is within 14 days of
the End Date (ED). This means that unless
the appointment is made immediately, the
clinic will fall outside the acceptable
range of dates.
Priority Three
The Clinic Date (CD) is after the Target
Date (TD), but not within 14 days of the
End Date (ED). This is an acceptable
position for the appointment to fall.
Priority Four
The Clinic Date (CD) is before the Target
Date (TD), but it is after the Start Date
(SD). This is an acceptable position for
the appointment to fall.
Priority Five
The Clinic Date (CD) is before the Start
Date (SD). There is no point in making this
appointment, as the patient will be seen
before they need to be.
4
Pick the patients
Pick the patients to send for in order of
highest priority (One is high) first, then
within the priority order, by Target Date.
Using the pick list as a monitoring
tool
A useful consequence of the prioritisation
system is that it gives continuing feedback
on the capacity available for return
appointments. If priority One or Two
patients are appearing consistently in the
pick list, the demand for appointments
exceeds the capacity and more must be
made available. If there are any priority
Five patients picked, there is too much
capacity, and some resources should be
diverted to seeing more new patients.
Acceptable Range
(Delay + and - 20% of the delay)
Delay (TD-RD)
Request
Date
RD
Start
Date
SD
Target
Date
TD
End
Date
ED
Priority 5
Priority 2
CD before
CD
within
14 days
Start Date
Priority 4
of
End
Date
CD between Start Date
Priority 3
and Target Date
CD between Target Date
and 14 days of End Date
Priority 1
CD past End
Date
Figure 12. Prioritisation of follow-ups
A guide to good practice
Page 57
3.3 The booking process
Direct booking: Appointments
within six weeks
referral to urgent. As already described
these patients are sent a “phone us now”
letter through the Appointment Centre,
and are in other respects handled as if
they were a partial booking referral. The
exception to this case is those patients
who fall within the “ten day” rule —
primarily cancer referrals. These are dealt
with separately on the following pages.
Because there is a six week cutoff,
appointments cannot be made into clinics
further than six weeks into the future, and
so partial booking is used. Within six weeks
from now it is possible to guarantee a
clinic and direct booking can be used.
Direct booking for new referrals
There are two circumstances that apply
with new referrals. One, the preferred
situation, is called GP direct access
booking and it is covered shortly. The
second is where the referral is received
through the normal “non-urgent” mail
referral, but the GP has marked the letter
urgent or the consultant has upgraded the
Direct booking for follow-up patients
This is almost the trivial case of direct
booking, as it is no change from the
traditional practice. Where a follow-up
appointment is required within six weeks,
it is made in person at the reception desk
before the patient leaves the clinic. The
only difference from traditional practice
is that the appointment
will be easier to make —
High Level Flow Chart
because the clinic will
GP Referral process
not be clogged up with
long term follow-ups
I want to refer
already booked in some
this patient
months earlier.
Process on-line
Process by phone
Patient meets
relevant
guidelines for
urgency
Yes
Is referral
urgent or
soon?
GP direct access
Phone
Appointment
Centre
No
Is referral
urgent or
soon?
Make
appointment
on-line
Register for
Partial
Booking
Yes
Appointment
made over
phone
Produce letter
for patient
Produce letter
for patient
Complete online referral
form
Fax referral
letter or form
within 48
hours
Patient
attends
appointment
Feedback
form received
monthly
No
Appointment
Centre posts
out Partial
Booking
Letter
Allowing GPs direct
access to booking systems
will provide a greater
degree of confidence to
the GP and the patient
that they are being
appropriately cared for
by the Trust. While GP
direct access may be
based on technology,
there is also the option of
implementing GP access
through existing phone
technology by use of the
appointment centre.
The flow chart in figure
13 illustrates how both
full and partial booking
would work under either
system.
Figure 13. GP referral process
Page 58
A guide to good practice
3.3 The booking process
The NHS in Wales is not currently trying
to achieve a system where all outpatient
appointments are booked by the GP.
Because there is a system in place that
means no patient is booked over 6 weeks
into the future (partial booking), GP
access to clinics with waits over 6 weeks
will result in registering the patient for
partial booking rather than allocating a
specific appointment time.
One of the advantages to direct access
booking is that it allows short notice
appointments (under six weeks) to be
allocated at the time that the patient is
in the GP practice, reducing both time
and work at the Trust. Another advantage
is found if an automatic process is put in
place to provide feedback to GPs on the
referrals they make — this is covered in
chapter 6 under “GP Feedback”.
week, or if the clinic did not have to
adhere to a ten working day standard,
there would not be a problem — patients
would be booked further ahead, and it
would “all average out over time”. With
the ten day standard, a couple of weeks
of higher than average referrals will
breach the standard.
Some weeks there are more slots than
patients...
As with the “too many patients” problem,
there will be some weeks, or a run of
weeks, with too few patients to fill the
available slots. Because the number of
slots is based on the average number of
referrals, using these vacant slots at the
last minute eats into the supply of slots,
yet if not used, they are wasted — the
next referral cannot be booked into a slot
last week just to “average” the clinics
out!
Booking “Ten Day Wait” patients
The Assembly has a requirement that
certain categories of patients (primarily
some patients with suspected cancer) are
seen within ten working days. Booking
systems must be set up to ensure that
these patients will be seen within the
required time.
One of the problems in meeting the
requirements of the 10 working day
guarantee involves ensuring that there are
enough appointment slots for these
patients every week. Normal booking
processes attempt this by
setting aside an average
number of slots for urgent
and cancer referrals. This
does not work.
What is the solution?
The problem is one of allowing adequate
slots for a “run” of above average
referrals, yet not wasting slots by
providing more slots than there are
referrals. The challenge is to provide this
without overbooking or underbooking the
clinic — the right number of patients
arriving at every clinic.
One approach to this problem uses the
Appointment Centre and patient focussed
booking. The number of slots each week
Number of cancer referrals each week, with average and maximum
9
8
7
number of referrals
6
5
Some weeks there are not
enough slots...
Because the clinics are
planned for the average,
there will be some weeks
when there are not enough
slots. If this is an isolated Figure 14. Average and maximum cancer referrals
4
3
2
1
0
00001
00004
00007
00010
00013
00016
00019
00022
Referrals
A guide to good practice
00025
00028
Maximum
00031
00034
00037
00040
00043
00046
00049
00052
Average
Page 59
3.3 The booking process
is set to almost the maximum referrals
received in any week (actually to the 80th
percentile). This sets aside more slots
than there will be patients most weeks.
Innovations in Care recommends using
data from a full year for this calculation.
Any vacant slots in the current week are
filled with routine patients, or other GP
referrals, if there are no ten working day
referrals. There is no danger of breaching
the ten working day wait rule, as there
will almost certainly be enough slots next
week for however many patients are
referred, even if all this week’s slots are
filled.
Because there are always patients phoning
for appointments, slots not used during
the preceding week can be filled. The
process is described diagrammatically in
figure 15. The template shown includes
two clinics per week (Wednesday and
Friday, shaded) and a calendar is shown
for four weeks.
The first column shows the situation on
the first Tuesday (3rd). The cancer slots
in the two clinics that fall between six
working days and 10 working days (the
clinics on the 11th and 13th) are strictly
reserved for cancer patients only. The
slots in the clinics between today and five
working days (the clinics on the 4th and
6th) may be used for any cancer referrals,
but they may also be used for any other
patients who phone for appointments —
even if they are routine appointments.
Two days later (on Thursday 5th) the
situation has changed. The time periods
are now shown in the middle column. The
0 to 5 working day period (reversed) now
includes the clinic on Wednesday 11th,
and any cancer slots in this clinic are now
available to be filled by any patient who
phones in. The loss of those slots to cancer
referrals is compensated for by the fact
that the clinic on the 18th is now available
for cancer bookings.
Clinics
Monday 02
Tuesday 03
Wednesday 04
Today
0 to 5 days
Thursday 05
Clinics falling within
Friday 06
this time frame can
Today
0 to 5 days
Saturday 07
be used for ANY
Clinics falling within
Sunday 08
(cancer or routine)
this time frame can
Monday 09
patients
be used for ANY
Tuesday 10
6 to 10 days
(cancer or routine)
Today
0 to 5 days
Cancer slots in
patients
Clinics falling within
Thursday 12
clinics falling within
6 to 10 days
this time frame can
Friday 13
this time frame can
Cancer slots in
be used for ANY
Saturday 14
ONLY be used for
clinics falling within
(cancer or routine)
Sunday 15
suspected cancer
this time frame can
patients
Monday 16
referrals
ONLY be used for
6 to 10 days
Wednesday 11
The following week,
the situation has
changed again (third
column). Once again,
the clinics within 0 to
5 days (those on the
11th and 13th) are
now available for any
referral, while those
in the 6 to 10 day
frame (18th and 20th)
are reserved for
cancer patients only.
Figure 15. Booking “10 day wait” patients
The moving template
will continue to slide
on through the month
— always reserving at
the very least one full
week of clinics within
the 10 working day
deadline, yet backfilling any slots not
used by day 5 with any
referral.
Page 60
A guide to good practice
Tuesday 17
suspected cancer
Cancer slots in
referrals
clinics falling within
Wednesday 18
Thursday 19
this time frame can
Friday 20
ONLY be used for
Saturday 21
suspected cancer
Sunday 22
Monday 23
Tuesday 24
Wednesday 25
Thursday 26
Friday 27
referrals
3.3 The booking process
Where this system is in use it is possible
to ensure that all patients are seen within
the 10 working day target, without
wasting capacity or overbooking clinics.
Patient focussed booking,
inpatients and day cases
The system of booking outpatients
described above cannot simply be
extended to inpatients or day cases.
Appointment Centre staff are unlikely to
have the expertise or access to
information needed to make up theatre
lists, which will require matching groups
of patients with varying length procedures
to make best use of skill mix, equipment
and time. Yet the benefits of patient
focused booking will be even more
significant in booking theatre lists where
the costs are so much higher than
outpatient clinics.
Booking as a two stage process
The best approach to booking for inpatient
and day case surgery is to treat it as a
two stage process. First book the preoperative assessment, and then book the
actual surgical date at the pre-operative
assessment.
The Preoperative assessment
appointment
Where the patient is to receive surgery
within six weeks of being placed on the
list, the preoperative assessment should
be completed at the time of the
outpatient appointment. In many Trusts
this is done within the day surgery unit or
on the appropriate surgical ward, and the
patient is directed there from the
outpatient clinic.
Where the wait is longer than six weeks,
the patient is listed in the normal way
and advised of the likely wait. The
preoperative assessment is then treated
as if it was an outpatient appointment.
An appointment is booked for a
preoperative assessment in a clinic run
A guide to good practice
on the ward or in the Day Surgery Unit.
This is booked using the partial booking
process through the appointment centre.
Because the assessment is likely to be
relatively generic, there are none of the
problems of booking the appointment
directly for theatre.
Preoperative assessment clinics can be
booked for a range of theatre lists. It is
not necessary for all patients on a list to
be booked into the same assessment
clinic. “Phone in” letters for the
assessment clinics can be generated on
the basis of an “average” flow through to
the actual theatre list, as the actual
matching of patients to lists can be done
at the preoperative assessment when the
patient attends in person.
Arranging surgery at preoperative
assessment
When the preoperative assessment is
completed and the patient is clearly fit
for surgery, the list can be booked. There
will be a range of theatre lists over the
next six weeks available to the person
doing the booking, and if necessary the
booking could be made slightly further
into the future. Because the staff doing
the assessment are also doing the booking,
the issues of casemix on the list do not
apply — the specialist knowledge required
is held by the preoperative clinic staff.
In some cases it may not be necessary for
the patient to attend for a preoperative
assessment. In these cases, an assessment
may be carried out over the phone.
Telephone preoperative assessment
Telephone assessment is best done by
writing to the patient and inviting them
to contact the appropriate department at
a date and time convenient to themselves
within a given range, eg. Monday to Friday
between 2pm and 6pm.
Page 61
3.3 The booking process
On contacting the department the patient
is asked a series of questions, and is either
deemed fit to proceed to negotiate a date
for admission and surgery, or it is felt that
the patient will need to attend for
outpatient preassessment and therefore
the date for this will be negotiated with
the patient whilst on the phone.
At the time of the telephone call, the date
and time for surgery are agreed as if the
patient were present at the pre-op
assessment clinic.
The booking of preoperative assessment
clinics and the impact on theatre
performance is covered in more detail on
page 71.
Partial Booking in Diagnostics and
Therapies
Diagnostics and Therapies fall between
the simplicity of booking outpatients and
the complexities of booking theatre lists.
In most cases, the lists will be able to be
booked through the Appointment Centre
as long as particular attention is paid to
the setup process and training
Booking Inpatients and
Day Cases:
Patient is listed for
Overview
surgery
Will the patient receive
surgery within 6weeks?
No
Yes
Preoperative Assessment
completed same day as
outpatient appointment
Patient is placed on a waiting list
until the appropriate time
Staff at pre-op book date
and time of theatre list
Patient is sent a letter asking them
to phone the Appointment Centre
and make a booking for pre-op
assessment
Confirmation is sent out by
mail
Does the patient phone?
No
Reminder and removal
process
Yes
An appointment date and time for
pre-op is agreed on the phone
Confirmation is sent out by mail
Patient attends pre-op assessment
and is assessed as fit for surgery
Staff at pre-op book date and time
of theatre list
Confirmation is sent out by mail
Figure 16. Booking inpatients and day cases
Page 62
A guide to good practice
3.3 The booking process
Appointment Centre staff to deal with
these more specialised clinics.
One specific problem that may be seen is
that many services have no access to the
PAS, or use a computer system that is
independent of the PAS. This means that
many of the issues seen in the early stage
of setting up outpatient booking will need
to be revisited. Either partial booking
capabilities will need to be put into the
existing diagnostic computer systems, or
a link will need to be made to the PAS.
Where systems are manual, they will need
to be set up as PAS clinics, which will
involve some network and equipment
issues.
As the NHS in Wales moves towards
measuring waiting times in Diagnostics and
Therapy services, integrating booking
systems with those in the main clinical
specialities is essential. Too often in the
past problems in diagnostics and therapies
have been overlooked, but that situation
is changing.
Implementing patient focussed
booking
Patient focussed booking will lead to
significant reductions in DNA rates and
cancellation rates. As many consultants
have taken DNA rates into account when
calculating clinic sizes, an important step
in introducing patient focussed booking
must be to review the clinic profiles.
Step 1: Meet with the medical staff
There is less potential for confusion
amongst staff if patient focussed booking
is introduced speciality by speciality,
rather than consultant by consultant. This
means that clerical staff in the medical
records area do not have to decide
whether a generic referral has to go to
the new or the old process. Staff in clinics,
who may need to answer questions about
referrals, will be less confused. Overall
the change will be smoother.
A guide to good practice
It is important to approach each
consultant individually. Avoid working
solely through third parties, such as a
Clinical Director. A group meeting with the
consultants in a speciality may be an
alternative if individual meetings are not
possible, but ensure that a follow-up
meeting is arranged with any staff not
present. There are a few outcomes that
must flow from the meeting.
Adherence to a six week leave policy
You must get the agreement of the
consultant staff that they will adhere to
a six week notification of leave policy. This
is essential. In changing the system, you
are removing some apparent certainty for
the patient in return for far greater
certainty that their appointment will not
be cancelled. Without agreement from
consultant staff that they will not cancel
clinics at short notice, you are unable to
give that certainty to the patients who
phone in. This is the only concession that
you will require from the consultant staff,
and most will see it as a small imposition
— in fact, there are likely to be only a
small number who do not do this already.
The notification period must apply to the
junior staff as well — in fact, to all staff
whose absence would lead to the
cancellation or reduction in size of a
clinic. In general, consultant staff are
much better at adhering to this policy than
are junior staff. This may reflect the fact
that we are poor in communicating with
junior staff due to regular rotation, and
it will be useful to ensure that this policy
is covered in any orientation material sent
out to new staff.
One reason for short notice cancellation
by junior staff is that leave is applied for
in another run or hospital, and the staff
arrive in a new department with preapproved leave for the next week. Good
communication and orientation practices
should reduce this problem.
Page 63
3.3 The booking process
Of course, having the agreement of staff
to adhere to a six week policy will only
work if the processes are in place to
ensure that leave notification is promptly
acted upon. It is essential to have clear
leave approval procedures that ensure
clinics are able to be closed off within a
few days of the leave being requested,
otherwise clinical staff who adhere to the
policy will still see clinics cancelled, but
for purely administrative reasons. A clear
policy backed up by good and prompt
procedures will make the process work.
Clinic profiles
Consultant staff must review their clinic
profiles. The new profiles must assume
there will be no DNAs. Do not accept an
assurance that the profiles are OK —
review them anyway. This is likely to be
the most time consuming stage of the
process.
Implementation timetables
Ensure that all staff understand that the
new system will not have an effect until
all patients currently booked into the
system are seen. A common misunderstanding is that the patient focussed
booking is not working because clinics are
over booked six weeks after the meeting
— but the clinics were booked up 12 weeks
ahead, and are still working under the old
system.
After the meeting, send a letter to each
consultant thanking them for their time,
and reconfirming the six week rule, the
commitment to review
the clinic profiles (with a
Patient focussed booking and
date for the first draft)
patient transport
and a date by which the
Some patients need help getting to their appointment. This clinic should be operating
transport is organised by the GP practice once an appointment fully.
has been made by the Trust. The cost of transport is met, not
by the GP, but by the Trust.
This system causes a number of problems. Often transport is
booked too late, and the patient DNAs. Frequently an
appointment is cancelled, but since transport is arranged
through the GP practice, no one knows to cancel the transport.
GP practices spend a lot of time arranging the transport.
There is no accountability between the Trust and the GP when
one organisation is paying and the other does all the ordering.
With the Trust Appointment Centre making partial booking
appointments, there is an opportunity to fix these problems.
Patient transport bookings should be made by the Trust
Appointment Centre at the time the appointment is made.
Use of a clear script to elicit whether transport is required
will reduce unnecessary use. The transport booking should
be recorded on the PAS, so that if an appointment is cancelled
the transport can also be cancelled.
This system reduces transport “DNAs”, and Trust DNAs caused
by failure of the transport process. It reduces the cost to the
Trust of patient transport. It eliminates the need for the
patient to contact their GP to arrange transport, and it
reduces workload in GP practices who no longer have to be
involved in the process.
Page 64
Step 2: Meet with
other clinic staff
Before working on
profiles, it will be useful
to meet with the nursing
and clerical staff for the
speciality. The purpose to
the meeting is to explain
the new booking system
to them, and to get any
information they may
have on quirks of the
clinics. Once again stress
how the new system will
resolve
current
problems, and aim to get
them enthusiastic in
support of the changes.
Dissatisfied staff in the
clinic can do a lot to sway
the consultant staff
against change, and staff
who are on board will
help with the minor
A guide to good practice
3.3 The booking process
problems that
implementation.
will
arise
during
Step 3: Prepare the profiles.
Start from the existing clinic lists – not
the booking rules on the system, but the
lists of actual attendances in clinic. Often
the clinic profiles on the system bear little
resemblance to the actual booking rules,
which may exist solely in the heads of the
consultant and clerk.
staff as being workable. Remember that
they must not include any assumed
cancellations or DNAs. Also check that the
number of new referral slots will allow
the Trust to see the number of patients
referred. Be careful of allowing clinic
numbers to drop significantly unless there
are clear reasons why the clinics were
previously overbooked. It is important to
not create a problem of reduced capacity
through this process.
Determine how many slots need to be Finally, set up the new profiles on the
reserved for urgent patients — based on system to start from the date that you
how many patients attend within seven have determined all previously booked
days of referral. How many acute patients patients will have been seen.
are seen? How many soon? Are the clinics
made up of new and follow-up patients, Step 4: Start patient focussed booking
or are there separate clinics for new for this speciality
patients? Analysis of the clinics for the The system “goes live”.
past few months should give a good
starting point for this information. Step 5: Review the booking rules
Determine both the average figure and Once patient focussed booking is
the maximum in any particular clinic — it implemented, and several clinics have run
is
important
to
determine whether there
Booking and mail costs
is much variability in
types of referral, or One concern about the use of booking is that the system will
whether the referral increase costs. It is true that there are more mail costs, and
in some cases extra staff may be needed in appointment
rates are predictable.
centres.
Avoid “carve-out” caused
by allocating too many
“slot types”. Reduce the
number of types of slots
to a basic four: new
referrals under two
weeks; new referrals
over two weeks; followups under six weeks;
follow-ups over six
weeks. See page 95 for
more detail on carve-out.
Once the booking rules
are drafted based on this
information, confirm
them with both the
consultant and the clinic
A guide to good practice
There are ways to reduce the costs however. Many staff are
involved in printing, checking and enveloping appointment
letters at present, and there are also mail costs involved in
the current system. One potential solution being investigated
by Trusts in England and Wales involves forming a partnership
arrangement with an outside contractor to print and process
the letters.
In this system, letters are sent electronically to a print bureau,
who sort the electronic file by postcode, print and despatch
the letters. The sorting of the files means that Trusts can
take advantage of Royal Mail discounts on postage, and less
space and capital expenditure is taken up by printers and
enveloping machines. Where Welsh language is required, the
use of fast duplex printers allow the printing of English and
Welsh on opposites sides of the page, again reducing cost.
It is also possible to use the checks in this system to reduce
wrongly addressed mail.
Page 65
3.3 The booking process
where all patients have been booked
through the new system, go back and meet
with the staff again to determine whether
any changes need to be made to the
booking rules. It is quite possible that
there were perceived problems that have
led to under booking, or that insufficient
slots were removed to allow for the
reduction in DNAs.
Step 6: Diary dates for regular review
of the booking rules
Things change. Don’t assume that getting
things right the first time will mean that
the booking rules are set in stone. All clinic
profiles should be reviewed at the
minimum annually. This review should
include start and finish times, the number
of new and follow-up slots, and the
timings of appointments. The review
should be conducted as part of the process
of balancing annual capacity and demand,
so that increases or decreases in demand
over the year can also be addressed.
Setting Up an Appointment Centre
The heart of the patient focussed booking
system is an efficient phone centre. Avoid
the use of the term “call centre” as it
sometimes has negative connotations, but
there is no doubt that the system depends
on a dedicated team of staff who can
accept calls and make appointments.
Setting up a centre is no different than it
would be in any other industry, and it is
useful to benchmark your service with call
centres from outside health. The
requirements are simple:
1: Location
The Appointment Centre must be
somewhere where mail access for external
(referral) mail and internal mail is
delivered several times a day. While in
theory it is possible to site the centre
anywhere, proximity to the trust will
make phone and computer connections
simpler.
2. Equipment
Dedicated phone lines are essential. These
should have a single number for the public
to call, feeding into multiple operator
lines. Look into the availability of
specialist equipment — eg call distribution
software that randomly allocates calls to
the operators, headsets to allow hands
free operation, and phones which allow
staff to complete transactions on their
computers before accepting another call.
Figure 17. The Appointment Booking Centre at Cardiff and Vale NHS Trust
Page 66
A guide to good practice
3.3 The booking process
3. Staffing
The Appointment Centre should be staffed
for extended hours and staff need to be
employed on contracts that allow shifts
to cover these times. Full training of staff
will be necessary.
4. Training
The Appointment Centre is as much the
public face of the Hospital as the Accident
and Emergency Department or the
Outpatient Clinic. For the majority of the
public accessing the services of the
hospital, the Appointment Centre is likely
to be their first contact
with a hospital staff
One stop clinics including
member. For this reason
it is extremely worthpre-operative assessment
while to put time and
Conwy & Denbighshire NHS Trust
energy into the public
In response to the ongoing quality development programme in
relations skills of the
Ophthalmology it is now common practice for patients to attend
their new letter clinic appointment, be placed on the surgical Appointment Centre
waiting list and undergo preoperative assessment all within Staff.
the same visit.
It is recognised that for most referrals, the reason for referral
may be identified (NHS Executive 2000). The patient is
therefore sent an information booklet regarding the condition
they are referred with prior to their appointment. This process
provides the patient with sufficient opportunity to be informed
before their appointment.
This practice meets with best practice recommendations and
is evidence of improved efficient and effective patient
preparation preoperatively to reduce cancelled surgical cases
at short notice. The objective of preoperative assessment
clinics incorporated at listing in the clinical area is to provide
efficient delivery of ophthalmic services to the patient in an
informative manner. Careful planning and health education
processes provided during this process enables the Directorate
to plan duty rosters, skill mix and full theatre utilisation.
Several Trusts in England
and Wales use a training
programme with an
external agency who
specialise in telephone
skills, covering all
aspects of dealing with
the public by phone. The
programme, spread over
four half day sessions, has
been tailored to the
specific problems and
questions likely to arise
in a call centre dealing
with patients.
One-stop clinics for surgical listing take place daily at H M
Stanley hospital, and are planned at Colwyn Bay and Holywell
peripheral clinics. The success of these clinics is dependent
on resources and skilled ophthalmic staff supported by well
co-ordinated clinic bookings.
Future aims to improve this service will be to expand technical
resources available such as biometry, focimetry and keratomery
equipment to increase potential throughput.
The service provides patients with their admission date at this
assessment, when anaesthetic support is available for all
theatre lists.
It is planned to include all peripheral clinics in this one-stop
service to provide true equity of services in the NHS in our
catchment area of North Wales.
Reference: NHS Executive (2000) Action On Cataracts: Good Practice Guide
A guide to good practice
Page 67
3.3 The booking process
Sample Partial Booking Letters
Dear
I have received a letter requesting an
appointment for you to see a consultant
in Specialty.
A consultant has seen the letter and
asked us to make you a ‘non-urgent’
appointment.
Dear
You can now arrange an appointment
with
Consultant’s Name and Specialty
by phoning the appointments office on
0123 456 789 to agree a date and time.
The current waiting time for this kind of
appointment is ... months. (If the waiting
time will be longer than 6 months
include the following: We are very sorry
that you will have to wait this long for
your appointment. I can assure you that
we are doing everything we can to
reduce our waiting times). If you request
to see a specific consultant, your waiting
time may increase, and maximum
waiting time guarantees may not apply.
You can phone between 8am and 8pm
Monday to Friday. Outside these times,
you can leave a message on our
answerphone. Please leave your name,
hospital reference number (found at the
top of this letter) and daytime phone
number, and we will phone you back the
next working day.
Because we will need to write to you
about your appointment, please
remember to phone us if your address
or phone number changes.
If you have any questions please phone
us as soon as possible on 0123 456 789.
We will write to you five weeks before
your appointment is due, and ask you to
contact us. We will then arrange a
convenient date for you to see the
consultant, or a member of his or her
team.
If you no longer need to make an
appointment please let us know.
Yours sincerely
First invitation to telephone
Should your condition worsen while you
are waiting for your appointment, please
inform your GP.
If you have any questions please phone
us on 0123 456 789. You can phone
between 8am and 8pm Monday to
Friday. Outside these times, you can
leave a message on our answerphone.
Please leave your name, hospital
reference number (found at the top of
this letter) and daytime number, and we
will phone you back the next working
day.
Yours sincerely
Acknowledgement letter
(sent after prioritisation)
Page 68
Figure 18. Making an appointment in the North
West Wales Trust appointment centre
A guide to good practice
3.3 The booking process
Dear
Dear
We recently asked you to make an
appointment to see
We recently asked you to make an
appointment to see
Consultant’s Name and specialty
Consultant’s Name and specialty
You have not yet arranged to do so.
Please contact the appointment office on
0123 456 789 to arrange your
appointment.
As you have not contacted us to make
your appointment we have assumed that
you don’t need your appointment. We
have now removed your name from the
waiting list.
If you no longer need to make an
appointment please let us know.
You can contact the appointment office
between 8am and 8pm Monday to
Friday. Outside these times, you can
leave a message on our answerphone.
Please leave your daytime number, and
we will phone you back the next working
day.
If you do not contact us within 2 weeks of
receiving this letter, we will assume that
you no longer need your appointment.
You will be removed from the waiting list.
We will also let your doctor know that
you no longer need your appointment.
We have also let your doctor know that
you have decided not to see the
consultant.
If you have any questions please phone
the appointment office on 0123 456 789.
Yours sincerely
Letter to patient advising of removal from the
Outpatient Waiting List
Dear Dr
If you have any questions please contact
the appointment office.
You referred
Yours sincerely
Patient Name, Address, NHS Number,
CRN
Reminder letter sent when patient has
not responded.
to Consultant Name and Specialty.
We have written to your patient twice
over the last 4 weeks to ask them to
telephone the appointment clerk to make
an appointment.
They have not responded and have
therefore been removed from the
outpatient waiting list.
If you have concerns about your patient
not being seen, please contact your
patient and then, if necessary, the
appointment clerk on 0123 456 789.
The patient can then be reinstated on the
waiting list at their original position.
Yours sincerely
Letter to GP advising of patient’s removal
from the Outpatient Waiting List
A guide to good practice
Page 69
3.3 The booking process
Dear
Dear
Recently you phoned the appointment
centre to make an appointment to see
You have been on the waiting list for
Consultant’s Name and Specialty.
As we agreed on the phone, an
appointment has been made for you on
day at time
This appointment will be at
location
Enclosed with this letter is a map
showing you how to get to the
appointment, and indicating parking and
public transport stops.
Also with this letter is an information
sheet that you should read before you
come to the hospital. It tells you
important information about the clinic
you are going to attend.
If for any reason at all you are not going
to be able to attend your appointment,
please phone us on 0123 456 789. This
will allow us to offer your original
appointment to some-one else. We will
be able to arrange another date and
time while you are on the phone.
If you have any questions please phone
us on 0123 456 789. You can phone
between 8am and 8pm Monday to
Friday.
Consultant’s Name and Specialty.
We are now able to offer you an
appointment to have your surgery.
In order to arrange your surgery we need
to see you in a pre-operative assessment
clinic. This clinic allows us to check your
general health and fitness for surgery,
and it will also give you a chance to
discuss your operation with staff. You will
also have the opportunity to book a
convenient date and time for your
surgery at this appointment.
Also with this letter is an information
sheet that you should read before you
come to the hospital. It tells you
important information about your surgery.
Please phone our appointment office
on 0123 456 789 and arrange a
convenient date and time for your
appointment. You can phone between
8am and 8pm Monday to Friday.
If you no longer wish to have your
surgery please phone us and let us know.
If you have any questions please phone
us as soon as possible on 0123 456 789.
Yours sincerely
Yours sincerely
Appointment acknowledgement letter
(sent after phone booking made)
Page 70
Partial booking letter for pre-operative
assessment (sent when patient is to be
brought in for assessment)
A guide to good practice
3.4 Pre-assessment for theatre
Pre-assessment for theatre
It is evident that the efficient and effective use of theatres are essential
to the provision of good and timely patient care. Too often patients are
booked for admission on times or dates that they cannot attend, their
surgery is cancelled at the last minute, or they are admitted and then
found to be unsuitable for surgery.
Preoperative assessment
Figures for the period April to June of 2003
show that out of all the cancelled
operations in Wales, 47% were instigated
by the patient. 35% of these
postponements or cancellations were on
the day, or one-day before surgery was
due to take place. The main reasons for
the surgery not happening, as shown in
figure 19, were that the patient did not
attend or that the patient cancelled the
surgery because the date was
inconvenient.
Innovations in Care recommends that
preoperative assessment should be carried
out not more than six weeks before the
anticipated date of surgery but not so
close that organising another patient (in
the event of the first patient being unfit)
is difficult. It is advisable to have a list of
patients who are willing to attend at short
notice. The patient’s assessment should
not only evaluate suitability for surgery
but should also take into account
suitability for anaesthetic, understanding
of what the procedure and its aftercare
entails. Planning for discharge and any
follow-up social care can also be discussed
and instigated and the opportunity taken
(Modernisation Agency, 2003)
Trusts that have effective
and timely preoperative
assessment have a lower
cancellation rate.
Reason for cancellations
The Modernisation Agency considers that:
“Pre-operative assessment
establishes that the patient
Top patient reasons for cancellation Q1 2003/04
is fully informed and wishes
to undergo the procedure. It
Appointment
ensures that the patient is fit
inconvenient
for the surgery and
anaesthetic. It minimises the
risk of late cancellations by
DNA
826
ensuring that all essential
resources and discharge
requirements are identified”
Operation not wanted
587
Unfit for surgery (pt
canc)
581
0
500
1000
1500
2000
2750
2500
3000
No of cancellations
Figure 19. Example of trust theatre utilisation report
A guide to good practice
Page 71
3.4 Pre-assessment for theatre
for a proper discussion with the patient The Audit Commission in Wales Acute
to ensure properly informed consent. The Hospital Portfolio report states that
consent form can be signed at this point booking patients before preoperative
with the patient confirming their decision assessment is common in most Trusts in
to proceed when
Wales, as shown by
they are admitted.
Good Practice Point figures 20 and 21.
At preoperative
Booking patients
assessment , if the
and informing them
Preoperative Assessment
patient meets all
of their date of
Preoperative assessment should be
relevant criteria,
surgery
before
undertaken six weeks prior to surgery,
negotiation redetermining if they
and should be booked using partial
garding date and
are suitable is one
booking. Preoperative assessment
time of admission
reason for the high
allows both staff and patient to check
within recognised suitability for anaesthetic and surgery,
number of cancelconstraints can take agree the booking date for surgery, and lations, and should
place, and a firm
be avoided by using
organise discharge arrangements
date for surgery can
the
booking
be agreed. This model fits well with the methodology described in chapter 3. A
booking process recommended by detailed flowchart of the process is shown
Innovations in Care described on page 62. in figure 22 opposite.
% Patients Pre-Assessed before offered date for
admission - Urology
Wales R
Wales R
% Patients Pre-Assessed - Urology
0
0
20
40
60
80
20
40
60
80
100
% of sample (data reproduced permission of Audit Comm ission in Wales)
100
% of sample (data reproduced perm ission of Audit Comm ision in Wales)
Figure 20b. Preassessment before booking,
Speciality A
Figure 20a. Preassessment, speciality A
% Patients Pre-Assessed before offered date for
admission - Orthopaedics
Wales R
Wales R
% Patients Pre Assessed - Orthopaedics
0
10
20
30
40
50
60
70
80
90
100
0
10
20
30
40
50
60
70
80
90
100
% of sample (data s upplied perm iss ion of Audit Com m ission in Wales)
% of sample (data reproduced perm ission of Audit Com m ission in Wale s)
Figure 21a. Preassessment, speciality B
Page 72
Figure 21b. Preassessment before booking,
Speciality B
A guide to good practice
3.4 Pre-assessment for theatre
Flowchart of the preassessment process
Immediately follow ing decision that operation
is necessary, patient undergoes initial
assessment
Patient meets locally agreed criteria
Patient added to
inpatient w aiting list
Patient added to day
surgery w aiting list
Contact patient 6 w eeks before anticipated operation date and
invite them to telephone to either undertake a telephone
assessment or discuss a suitable date and time for outpatient
preassessment (as appropriate)
Does patient need
tests or POA?
Yes
Agree date for reassessment or tests in
primary or secondary care
No
Re-assessment or tests
performed
Ask questions to ensure that no changes
in condition have occurred
Review by relevant
professional
No
Surgeon, anaesthetist & critical
care consultant (if appropriate)
to reconsider risks and benefits
w ith patient
Do benefits of
Surgery
outw eigh
risks?
No
Consider other forms of
treatment
*Agree is defined as ‘the patient
is able to choose from a
reasonable range of available
dates’. This should take into
account availability of resources
Does patient
meet locally
agreed criteria?
Yes
Yes
Agree* date of operation and any
necessary tests and give pre-operative
information and instructions
To minimise cancellations it is considered
best practice to confirm attendance prior
to admission
Perform any tests as required near time
of surgery
Are test results
satisfactory?
No
Treat patient to
correct
abnormalities
Yes
Patient has operation
Figure 22. Flow chart of the pre-assessment process.
A guide to good practice
Page 73
3.4 Pre-assessment for theatre
National guidelines for effective
preoperative assessment
The National Institute for Clinical
Excellence (NICE) has issued a clinical
guideline on the use of routine
preoperative tests in elective (preplanned) surgery for children and adults.
Carrying out lots of preoperative tests can
lead to unnecessary delays or cancellation
of operations as well as inconvenience and
discomfort to patients because of ‘false
positive’ test results. The NICE guideline
will ensure that health professionals have
clear recommendations about the tests
that should and should not be carried out.
of blood transfusion and alternatives in
surgical care. This can be achieved by
ensuring that mechanisms are in place for
the preoperative assessment of patients
for planned surgical procedures.
The website address to access these
guidelines is http://www.nice.org.uk/
cat.asp?c=56818
Website address for Modernisation Agency
Preoperative Assessment Guidance:
This also links to the directive delivered
in WHC (2003) 137 — Better Blood
Transfusions that states clinicians should
avoid the unnecessary use of donor blood
in clinical practice by securing
appropriate and cost-effective provision
Effective training to undertake
preoperative assessment
A training package has been developed by
the University of Southampton that equips
relevant professionals with the skills
necessary to perform effective
preoperative assessment. Details for
acquiring this can be found on the
Modernisation Agency website.
http://www.modernnhs.nhs.uk/scripts/
default.asp?site_id=28&id=7511
Preoperative Assessment
Co-ordinator in Surgery
Conwy & Denbighshire NHS Trust
During the development of an Integrated Care Pathway for patients undergoing Day Case
Hernia Repair Conwy & Denbighshire NHS Trust developed an evidence based preoperative
assessment phase. Following a successful pilot and evaluation the Modernisation Task
Group felt it was important to ensure that all patients undergoing surgical procedures
had equitable access to this quality service. A Preoperative Assessment Co-ordinator has
recently been appointed and their specific remit is to co-ordinate the modernisation of
preoperative assessment across all areas of the Trust.
A baseline audit of existing activity across the Trust is currently in progress and is aimed
at measuring where different areas are in relation to best practice. The audit is looking
at referrals systems, documentation, processes, environment, clerical, administrative
and clinical roles. A training programme for staff involved in preoperative assessment has
been developed, led and piloted by one of the Consultant Anaesthetists. It is hoped to
expand upon this and develop this training programme to provide centralised training for
all staff involved in pre-operative assessment across the Trust.
The preoperative assessment co-ordinator will play a key role in ensuring that the Trust
will have one recognised process and consistent standards for preoperative assessment
and should only be undertaken by suitably trained individuals in an environment conducive
to patient’s needs.
Page 74
A guide to good practice
Chapter 4
Essential
measures
for managers
Staff managing clinical departments need to understand a number of key
elements of the services they are responsible for. They must know the
capacity of the service, activity levels, and the level of demand on the
service; the processes that are involved in the service; and the
management of flow around constraints in the system.
Understanding the service:
Three essential measures for
managers
Many clinicians and managers do not fully
understand the services they work in.
There are a number of reasons for this;
Managers often talk about capacity and the NHS is poor in the provision of good
demand for services making assumptions information, many managers work in a
that (a) all their problems are caused by state of continual “fire-fighting”,
a lack of capacity,
clinicians
are
and (b) if only the
caught up in an
Good Practice Point endless progression
Local Health Board
commissioning the
of
overbooked
Managing Capacity and Demand
service
would
clinics
and long
Staff managing services in Trusts must
provide
more
waiting lists. There
have a clear understanding of the
capacity,
they
is a way out of this
capacity of their service, the activity
would be able to
information
levels provided by the service, the
improve services demand on the service, and the backlog vacuum.
and reduce waiting
of work in the system. For nontimes. This is not
outpatient work some element of
Innovations in Care
true.
casemix must be incorporated into the
recommends the
measures used.
Commissioning is
not the solution.
Time after time the requests for more
resources are refused, not because the
LHB is unwilling to improve services, but
because the requests are based on “more
of the same, at the same price” rather
than grounded in good information and
demonstrated need based on hard
information.
A guide to good practice
use of three key
pieces
of
information which
will provide the basis for informed process
change and performance improvement:
measurement of activity, backlog,
capacity and demand; process mapping;
and patient flow modelling.
Page 75
4.0 Essential measures for managers
The three tools are:
• Activity, Backlog, Capacity and Demand
graphs;
• Process Maps of the key processes in
the service;
• Flow Models of the use of key
constraints in the service.
This chapter deals with these three
essential tools.
Backlog
The waiting list needs to be converted to
the common measure. The backlog may
be the number of patients on the waiting
list, or it may be the number of patients
refused admission if measuring a process
such as bed utilisation. Once again the
patient numbers must be converted to the
common unit. In figure 24, backlog is
represented as the number of minutes of
theatre time on the cataract waiting list.
Capacity
The capacity of the
system is the time
that the resource is
available. In the
case of theatres,
this will be staffed
Activity
time in theatre. In
the case of beds,
the total bed nights
Capacity
Backlog
available.
For
Figure 23. Activity, Backlog, Capacity and Demand
outpatients, it may
be staffed clinic
Activity, Backlog, Capacity and
sessions. Capacity is usually measured in
Demand Graphs — the four measures
time: in the figure, capacity is surgeon
A common unit of measure
minutes in theatre.
Because it is important to compare the
four measures on a single graph, the same
measures must be used for each. In the Demand
example shown in figure 24, minutes of The demand on the service is all the
theatre time is used as a common unit, patients referred into the service from all
although there are other measures that sources, once again converted to a
common measure of time. In Figure 24,
can be used.
the referrals are recorded as minutes of
theatre time.
Activity
Activity, Backlog, Capacity and Demand in Theatre Minutes
Activity is the throughput
of the system — the
number of patients seen
in clinic, discharged from
the ward, or processed
through theatre. The
number of patients must
be converted to the
common unit of measure.
Figure 24 shows cataract
operations measured in
minutes of theatre time.
Demand
6000
5000
4000
3000
2000
1000
Backlog in Theatre Minutes
Activity in Theatre Minutes
Sep-97
Jul-97
Aug-97
Jun-97
Apr-97
May-97
Mar-97
Jan-97
Feb-97
Dec-96
Oct-96
Capacity in Theatre Minutes
Nov-96
Sep-96
Jul-96
Aug-96
Jun-96
May-96
Apr-96
Mar-96
Feb-96
Jan-96
0
Demand in Theatre Minutes
Figure 24. The combined graph: 4 key measures compared
Page 76
A guide to good practice
4.0 Essential measures for managers
A common graph
Figure 24 shows the four measures for the
cataract waiting list, plotted on the same
graph. The relationship between the four
measures can now be seen clearly. Graphs
of the four main measures for key
performance indicators should be
routinely produced and regularly
reviewed.
process, and looking at them from the
perspective of the service.
Flow models are about understanding
bottlenecks and determining whether we
are scheduling the work around the
constraint. In the example of figure 26,
the constraint is represented by the
second section of each bar. The graph
shows
that
the
scheduling of patients
in this theatre list is
not
around
the
constraint, and there
is a large amount of
wasted time.
Start
Conclusions
NHS managers do not
have the knowledge
they need to manage
services without an
understanding of and
regular monitoring of
activity, backlog,
capacity, demand and the constraints in
the system; the process from the patient
perspective and where there are
bottlenecks; the flow of work through the
service, and an understanding of how to
schedule care to make best use of scarce
resources.
End
One person
One place
One time
Figure 25. The process map
Process mapping
It is important to understand how patients
proceed through the service. The best way
to achieve this is through process
mapping. Process maps are the ideal way
to identify rework within the system,
constraints and bottlenecks, and
unnecessary process steps. It is unlikely
that any one member of
staff
will
fully
understand the whole
service until the
process has been
mapped.
08:00
08:30
09:00
09:30
10:00
Operating Theatre Flow Model
10:30
11:00
11:30
12:00
12:30
13:00
13:30
14:00
14:30
15:00
15:30
16:00
16:30
17:00
1
2
3
Flow Models
Process maps show the
service from the
perspective of the
patient. Flow models
are a way of analysing
the service constraints
and bottlenecks found
during the mapping Figure 26. The flow model
4
5
6
7
8
Anaesthetic
A guide to good practice
Operation
Post-Anaesthetic
Recovery
Page 77
4.0 Essential measures for managers
Rapid access nurse led
colorectal service
Conwy & Denbighshire NHS Trust
Historically patients presenting with symptoms including
rectal bleeding were assessed in the Outpatient department
and investigations initiated from that visit. The timing of
their outpatient appointment is dependent upon the
information provided by General Practitioners and
availability of Consultant and appointment slots. From the
patient’s point of view, a series of visits is often necessary,
depending upon the findings of the investigation and the
course of treatment.
A nurse practitioner was appointed in October 2002 with
the specific objective of improving access to endoscopic
diagnostic services. Following successful training and the
implementation of agreed protocols and treatment pathways,
urgent suspected colorectal cancer patients are seen and
diagnosed within 10 working days, reducing the amount of
visits to just one.
In addition, the nurse practitioner is able to diagnose and
treat common anal conditions such as Haemorrhoids and Anal
Fissures. This service involves close and timely follow-up
appointments to allow for successful outcomes.
The nurse practitioner performs 300 – 350 flexible
sigmoidoscopies per annum and 100 – 150 follow-ups.
Enabling nurses to perform such complex and necessary
procedures has resulted in a reduction in waiting times for
diagnostic services, freeing up the surgical colorectal
consultants to see more complex patients in the Outpatient
department.
Page 78
A guide to good practice
4.1 Activity, backlog, capacity and demand
Activity, backlog, capacity
and demand
An understanding of the dynamics of waiting lists is essential to managing
them. There are four key measures that must be understood and monitored
on a continuous basis if waiting lists are to be managed effectively. In
addition, it is vital to understand the two key types of limitations in the
system: constraints and bottlenecks.
Consider the following scenario: waiting
lists are increasing, and it is necessary that
they are reduced. The demand is 5000
patients per annum, and only 4500
patients are seen in clinic. Waiting lists
are going up by 500 patients per annum.
What should be done? The Trust asks the
commissioning body to pay for an
additional 500 cases.
Consider another: there is an increase in
waiting times for CT scans. The wait has
gone from 12 months to 18 months over
the past two years. The data supports the
impression that there are more referrals.
What should be done? The Trust asks for
an additional CT scanner.
The commissioner is asked for an
additional orthopaedic surgeon.
There is an unstated assumption behind
all three of these scenarios. The
consultant in clinic works 100% of the
time. The CT scanner is utilised 100% of
the time. The surgeon in theatre utilises
100% of the theatre time. These
assumptions are usually wrong.
Capacity is the ability to do work, not the
amount of work done. It may be true that
the CT scanner is working at 100%
capacity, but without data for both
activity and capacity, two separate and
distinct measures, that cannot be
assumed.
And again: waiting times for orthopaedic
surgery are over 18 months. The waiting
list is increasing. What should be done?
The NHS collects data on activity, but
rarely on capacity. Activity is measured
in patient numbers, and is
Constraint
collected
for
Bottleneck
commissioning purposes.
Demand
There are many systems in
place to automate the
data collection process.
To understand capacity,
we need to dig deeper. So
Activity
what is the relationship
between activity and
Capacity
Backlog
capacity, and how can
Figure 27. The four key measures, and the limiting factors
they be related?
A guide to good practice
Page 79
4.1 Activity, backlog, capacity and demand
Measuring capacity
Capacity is the resource available,
multiplied by the time it is available. The
capacity of an operating theatre is not
the number of patients operated on, but
the time the theatre is available to be
used. Because an operating theatre is
“hardware”, the annual capacity of an
operating theatre is theoretically 525,600
minutes (43,800 per month). This assumes
the theatre to be available for use 365
days a year, 24 hours a day. But theatres
must be staffed to be of use. A single shift
(7 hours per day, 5 days a week) would
give a monthly capacity of only 9,125
minutes, substantially
less.
Measuring activity
It is not possible to compare two items
measured in different units, so if the
intent is to compare activity to capacity,
activity must be measured in time as well.
In the case of outpatient activity, this is
relatively simple — assumptions are made
about how long it takes to see each
patient (usually longer for new patients
than follow-ups) and the number of new
and follow-up patients attending are
multiplied by those times. For theatre
lists, diagnostic tests, or inpatient
procedures, other measures are
necessary. The relative merits of various
Capacity and demand in CT
What about the surgeon?
For a given waiting list,
surgical capacity must be
reduced even further. A
typical calculation is that
a surgeon works 42 weeks
each year, so the actual
average
monthly
availability must reflect
that reduction. It must
also take into account
the number of lists
(hours) each week that
the surgeon spends in
theatre. Typically, three
half day lists would give
a surgeon a monthly
theatre capacity of 2,205
minutes.
There are two key points
here. Does theatre
capacity mean physical
capacity? Staffed capacity? Surgeon capacity?
And capacity is measured
in units of time, because
the important information is the time the
resource is available.
Page 80
Gwent Healthcare NHS Trust
In August 2002 the Radiology Directorate applied the capacity
and demand framework to CT services. There were long
outpatient waiting times and it was difficult to balance the
priorities of ward patients and urgent outpatients. There
was a perception that there was insufficient capacity to meet
demand.
The data for a two-week period showed that there was enough
capacity to meet current demand but not to address the
waiting list backlog. The process maps indicated a number of
tasks to be undertaken and regular monthly meetings were
introduced at one site. Some of the improvements to date
are:· An increase in the average number of patients seen per
session from 10 to 13;
· Improvement in timeliness of vetting of referrals;
· Delegation of some vetting from Consultant Radiologists
to radiographers resulting in less delay;
· Reduction in out patient waiting times from around 12 to
8 weeks partly by re-directing referrals to another DGH
within the Trust;
· Scheduling ward patients at the beginning of each session
to make it easier for Consultants to provide reports to
clinicians on the same day;
· Freed up radiographer clinical time by moving scheduling
to clerical staff;
· Improved attendance at the evening clinics by over booking
to allow for DNA’s;
· Introduced additional Monday morning session to treat
more ward patients;
· Developed booking template for all sessions;
· Re-organised porter support for the department.
A guide to good practice
4.1 Activity, backlog, capacity and demand
measures are covered later, but on a basic
level, calculate an estimated time for
each procedure, and use that time rather
than patient numbers when calculating
activity. Activity is measured as the total
number of patients processed, multiplied
by the time it took to process each
patient.
Measuring Demand
In order to compare capacity and activity
to demand, it must also be converted to
time. Demand must be measured by the
number of patients added to the waiting
list, multiplied by the time each patient
is likely to take having the appropriate
procedure. Demand should be measured
by the additions to the waiting list each
day, as historical demand may not show
patients added and then quickly removed
(for example, acute theatre cases which
will affect throughput, and appear in
activity data, but may not appear on the
waiting list).
It is also essential to ensure that total
demand is measured — in outpatients,
demand will include GP phone-in patients,
or patients sent up from A&E, not just the
“paper GP referrals”. And remember —
each patient is converted to time.
Measuring Backlog
The waiting list is also measured in terms
of time. Converting waiting lists to theatre
minutes is not difficult. Estimated times
for each procedure can usually be
obtained — in the case of theatres, this
data is usually captured in the theatre IT
system. The appropriate time can then
be allocated to each patient on the
waiting list, and the total waiting lists
expressed in theatre minutes can be
captured at the end of each month. Be
careful not to use the average theatre
time — see the end of this section for the
best way to calculate estimated times.
The common graph
The graph below shows the four measures
for one such list, plotted on the same
graph. The relationship between the four
measures can now be seen.
Why theatre minutes?
Figure 29 on page 82 show the dangers of
not using time as a measure. Figure 29a
is a graph showing the number of patients
Activity, Backlog, Capacity and Demand in Theatre Minutes
6000
5000
4000
3000
Backlog in Theatre
Minutes
Capacity in Theatre
Minutes
Activity in Theatre
Minutes
Demand in Theatre
Minutes
2000
1000
0
Figure 28. The standard presentation of the four measures
A guide to good practice
Page 81
4.1 Activity, backlog, capacity and demand
are selectively removed. The
ability to identify easy work,
as a way of keeping lists low,
is reduced. Ultimately, a
point will be reached when
the patient numbers will rise
rapidly, because the
remaining cases on the
waiting list are all time
consuming ones.
Waiting List comparison of Day cases and Theatre Minutes
2000
1950
1900
Patients on List
1850
1800
1750
1700
1650
1600
1550
What measures should
be used?
29/10/2001
15/10/2001
01/10/2001
17/09/2001
03/09/2001
20/08/2001
06/08/2001
23/07/2001
09/07/2001
25/06/2001
11/06/2001
28/05/2001
14/05/2001
30/04/2001
16/04/2001
02/04/2001
1500
The examples on this page
use theatre minutes as a
Figure 29a. Waiting list in patient numbers, including trend
measure. This is a useful
on a day surgery waiting list, expressed measure for surgery, where theatre time
as patient numbers (or FCEs). The curved is likely to be the most expensive and
line represents a trend for the waiting list, scarce resource, but other measures must
and it can be seen that the trend is down be used in other situations.
but levelling off. The data line shows a
drop over the first part of the graph, with
a levelling off towards the end. Clearly, Bed nights
the waiting list has reduced and is under Bed nights, measuring length of stay, is
useful for medical patients and situations
control.
where there are bed shortages. For
activity, measure actual bed nights; for
Figure 29b tells a different story. On this capacity, number of bed nights in the time
graph, the waiting list converted to period; for demand, the estimated length
theatre minutes is superimposed on the of stay for those patients booked. Backlog
original. The trend now looks somewhat is measured by the estimated length of
different. After hitting a low point part stay for those patients whose operations
way through the year, the waiting list has were cancelled.
started to rise again. It is not under
control. Which is correct? Why are they
different?
Patient Numbers
Poly. (Patient Numbers)
Waiting List comparison of Day cases and Theatre Minutes
Waiting list numbers
measured by patient
numbers leave open the
possibility of searching the
list for short (easy, cheap)
cases as a way of reducing
quickly the number on the
waiting list. The result of this
practice is to increase the
weight of the casemix of the
remaining patients — the
casemix on the waiting list
becomes steadily more time
Patient Numbers
Theatre Minutes
Poly. (Theatre Minutes )
Poly. (Patient Numbers)
consuming as the easy cases Figure 29b. Waiting times in patient numbers and theatre minutes
2000
59000
1950
58000
1900
Patients on List
56000
1800
55000
1750
54000
1700
53000
1650
52000
1600
29/10/2001
15/10/2001
01/10/2001
17/09/2001
03/09/2001
20/08/2001
06/08/2001
23/07/2001
09/07/2001
25/06/2001
11/06/2001
28/05/2001
50000
14/05/2001
1500
30/04/2001
51000
16/04/2001
1550
02/04/2001
Page 82
Theatre minutes on List
57000
1850
A guide to good practice
4.1 Activity, backlog, capacity and demand
Diagnostic machine use
For equipment like ultrasound, CT, MRI,
endoscopy etc., session time and
procedure time make useful measures.
Remember that as with theatre time, the
equipment is not useful unless the
operator is also available, so capacity is
the number of operator hours, not the 24/
7 equipment availability.
Clinics
Outpatient clinics and therapy clinics
should be measured as resourced clinic
time. Where courses of treatment are
involved such as a planned series of
physiotherapy appointments, these are
part of the demand on resources, and
should not be overlooked.
Case weights
In some countries, all resource allocation
and commissioning is done on the basis of
case weights. The case weight unit is a
measure of resource use, and takes into
account factors such as length of stay,
drug costs, theatre costs, ICU costs etc.
averaged for a DRG (Diagnostic Related
Group) or HRG (Health Related Group).
Case weights are useful measures of
resource use, as they give a relative value
to patients on the waiting list that is more
meaningful than the traditional NHS
measure of patient discharges, but case
weights are not ideal for improvement
work because they are not specific enough
in how a particular case weight is derived
— for example a short LOS condition with
a high theatre component may have a
similar case weight to a condition with a
long LOS and no theatre component.
Cash
There is one other measure that people
use to measure relative worth, and that
is cash value. In many respects cash is the
same as case weights as a measure for
improvement, although it does have the
added advantage of showing the actual
value of time saved or resource used. The
A guide to good practice
NHS is poor at realising the financial
impact of change (or lack of change).
Measuring improvement as money saved
can be a powerful argument when dealing
with commissioning groups.
Constraints and Bottlenecks
The graphic on page 101 contains two
other items it is necessary to understand
in order to manage capacity and demand:
constraints and bottlenecks.
Constraints
The constraint in the system is the factor
that ultimately restricts the capacity of
the system. In theatres, the constraint
may be the surgeon operating on the
patient. In outpatients, the constraint
may be space. In diagnostics the
constraint may be skilled staff to
undertake procedures. In every process
there will be a constraint which ultimately
limits the throughput of the system. The
constraint is not easily removed without
substantial investment in terms of
staffing, or facilities. Identification of the
constraint is an essential part of
understanding a service.
Once identified, the constraint should
become the most important part of the
process. Work should be scheduled so that
the maximum use is made of the
constraint. Resources at the constraint
should not be used for jobs that other staff
could do. It is poor management to have
surgeons fetching their own patients —
especially if the reason is to save money
on porters!
Bottlenecks
The bottleneck is altogether a different
beast. Health processes are complex and
full of bottlenecks. A typical bottleneck
in theatres may be portering staff — the
entire theatre system stops while waiting
for a patient to arrive from the ward
because of a shortage of porters.
Constraints cannot be removed without
Page 83
4.1 Activity, backlog, capacity and demand
Distinguishing between the constraint in
the system and the bottleneck currently
limiting activity is essential. Constraints
limit capacity — bottlenecks limit activity.
By removing bottlenecks it is possible to
increase activity until it gets close to the
capacity of the system — which the
commissioner is ultimately paying for.
Constraints and bottlenecks: A
three step process
1 Identify the constraint in the system.
Use process mapping (page 107) to
determine where the constraints are.
Rather than using the average (50th
percentile) you should use the 80th
percentile.
Take 100 patients who have cataract
surgery. The average (the median in this
case) length of the procedure can be
Graph showing length of operation
Number of patients
investment; bottlenecks are usually cheap
or even free to remove.
Average: half the
patients fall above
the line, half below
80th percentile:
80% of the
patients fall below
this point, 20%
above
Length of operation
2 Determine whether the process is
Figure 30. Average vs 80th percentile
scheduled around the constraint. Use
patient flow modelling (page 109) to found by sorting the patients by length of
procedure, then counting to the middle
determine this.
(patient 50) and seeing how long their
3 If not, use PDSA cycles to eliminate a operation took. If this figure is used, half
bottleneck (page 115) and then repeat the time the operation will take longer
step 2.
than you have allowed, and you will be in
danger of running short of time if several
4 When you reach the point where the
patients take longer than average (which
use of the constraint is maximised,
they will, 50% of the time). Variation will
analyse your capacity to determine
average out over a long period, but will
whether it is sufficient. If it is not, then
not average out over a small number of
it is time to meet with the
cases such as a theatre list. This is the
commissioning group — but now you
same issue seen in booking 10 day waits
have hard data.
(page 59) and described under carve out
(page 95).
Maximising use of the constraint:
The 80% rule
When calculating throughput do not use
averages. Averages are seductive; using
the average theatre time to calculate
theatre minutes on the waiting list may
seem like an obvious solution, but it will
usually under estimate the actual
demand.
Variation is a normal part of all processes
and clinical processes are no different.
Accounting for the variation is important
when doing the calculations in this
section, and averages hide variation.
Page 84
By counting up to the 80th patient (80th
percentile) and using that time, then you
are likely to have underestimated the
time needed on only 20% of occasions. It
is far less likely that you will have a run
of patients over the estimate.
Conclusion
Getting the measurement right and
measuring the right thing is fundamental
to the management of waiting lists, and
managing bottlenecks and constraints.
A guide to good practice
4.2 Process mapping: Understanding the whole
Process mapping:
Understanding the whole
Process mapping is ubiquitous within the NHS improvement movement.
There is one reason for this: process mapping is the single most useful
diagnostic tool for determining where problems lie. Understanding the
process from the patient perspective is essential if services are to be
improved.
There are two stages to process mapping.
First, understand what happens to the
patient, where it happens and who is
involved. Then examine the process map
to determine where there are problems
such as multiple hand-offs*, parts of the
process that are unnecessary or do not
add value, or parts of the process which
would flow better if undertaken in a
different order. These problems can be
addressed by designing a new more
streamlined process.
Second, use process mapping to
determine where bottlenecks and
constraints occur. Is use of the constraint
maximised? Do the patients flow through
the system without delays? This approach
is covered on page 109 in “Managing
patient flow”.
The high level process map
The first step in understanding any service
should be to get as many of the staff
together as possible, and attempt to map
the process at a high level. Choose clearly
defined start and end points; for a referral
process these may be the arrival of a
referral letter in the trust through to the
appearance of the patient in the
outpatient clinic. For a surgical admission,
these may be from the decision to place
the patient on a waiting list through to
discharge. The important thing is to be
clear which parts of the process are inside
the map and which are outside. At this
stage a quick mapping exercise by a few
staff may be useful to determine who will
be involved in a more detailed mapping
exercise. It is essential to have
representatives of all staffing groups
involved in the process at the main
mapping exercise, and a quick high level
map will help ensure no staff group is
forgotten. Do not forget to involve
patients in the mapping process.
At the mapping workshop, use “post-it”
notes to capture the information about
the patient journey down to the level of
“One person, one place and one time”.
This will ensure that hand-offs, multiple
Start
* Hand-offs are places in the process where the
patient, or patient information, is passed from one
member of staff to another. Hand-offs are not only
inefficient, they are also a source of clinical errors,
and should be eliminated where-ever possible.
A guide to good practice
End
One person
One place
One time
Figure 31. The high level process map
Page 85
4.2 Process mapping: Understanding the whole
staff, changes in location, and loops in
the process are all captured.
Arrange the “post-its” into order, and look
for:
• Things that are done more than once.
• Steps that do not add to the patient
outcome — ask “Why is this being
done?”
• Count the number of hand-offs.
• Identify where there are delays,
queues, and waiting built into the
process.
• Ask for each step whether the action
is being undertaken by the most
appropriate staff member.
• Look for “re-work loops” where
activities are taken to correct
situations that could be avoided.
It may be useful to re-draw the process
map to look at a specific issue. For
example, a process map can be drawn
with each staff group in a different column
to identify the hand-offs — a hand-off
occurs each time the process map moves
across to a different column.
Staff
Group A
Staff
Staff
Group B Group C
Figure 33. Focussing down on the detail
expanding out the process. This can be
done several times, each time expanding
and getting to a greater level of detail.
An example might be a map of the
cataract process. Initially map the whole
process from referral to discharge, with
each step representing a hospital
encounter. Then focus in on the step with
the longest waiting list — maybe the
surgical admission. Finally focus down to
what happens in theatre.
Any level of mapping is useful, and it is
rare for a group to undertake process
mapping without identifying at least one
step that some members of staff were
unaware of. Process mapping is basic and
simple — the best way to learn it is to do
it.
Some simple tips:
• Try photographing key steps of the
process and illustrating the map for a
staff presentation;
• Walk through the process with a patient
to check that all events are included;
Figure 32. Looking for hand-offs
Focussing in on the problem
Once the overall process map has been
drawn and the staff agree with the
process, it will be useful to identify where
there are bottlenecks in the process.
Which step causes the most delays? This
step can then be mapped in more detail,
Page 86
• Work to the 80% rule — there will be
differences in the process for different
patients — draw the map for the
majority;
• Involve everyone — remember, the
porter probably has a better idea than
the surgeon where the delays are in the
process.
• Don’t forget to include the patient.
A guide to good practice
4.3 Managing patient flow
Managing patient flow
Process Mapping looks at the care process from a patient perspective.
There is another tool that will help identify where the bottlenecks in the
process are, and how to maximise use of the constraint in the system.
Patient flow models look at the care process from a unit perspective,
bringing together a number of patient process maps to look at work flows
through the unit.
Flow models are the best way to analyse
the work of a unit, such as an endoscopy
suite, an outpatient clinic, or an operating
theatre. The process of building up the
model is simple if all the steps are
followed.
will nearly always be a surgeon operating
on a patient. In outpatients, it may be a
clinic room in use by a consultant. In an
endoscopy suite, it may be a “scoper”
examining a patient.
4. Draw the flow model
1. Map and agree the process
The process must be mapped to a high
level of detail. A detailed map of theatre
may cover the process from the arrival of
the patient in theatre until discharge from
recovery — each step involving one staff
member should be distinct.
Patient
Arrives in
Theatre
Local
Anaesthetic
administered
Surgeon
performs
surgery
Patient
taken to
recovery
Patient
leaves
recovery
Figure 34. Initial process map
2. Time the steps
For a session, record the times for each
step of the process.
3. Identify the constraint
The constraint is that part of the process
which is the ultimate restriction on the
amount of work that can be done. It is
the part of the process that cannot have
resources added to improve throughput
— it is often the most expensive part of
the process. In theatres, the constraint
A guide to good practice
Using graph paper, or a spreadsheet
programme, draw each patient as a
horizontal bar one above the other. Set
the horizontal axis to represent time, with
the start of the session on the left, and
the end on the right. Colour each stage
of the process a different colour — it may
help to colour the constraining process
red. The length of each line will now
represent the time each step of the
process takes, and multiple patients will
show as a series of horizontal lines (see
figure 36). Add up the total of the “red”
sections, and calculate it as a proportion
of the total time.
Patient
Patient
Start of
Knife to skin Operation End goes to Leaves
Patient Anaesthetic
Time
time
Recovery Recovery
1
08:30
08:45
09:12
09:23
10:30
2
09:43
09:53
10:17
10:26
11:10
3
10:44
10:52
11:13
11:21
12:35
4
11:45
11:52
12:15
12:25
13:20
5
13:15
13:21
13:51
14:14
15:18
6
14:27
14:39
15:05
15:13
16:15
7
15:30
15:38
16:03
16:12
16:53
Figure 35. The flow data
Page 87
4.3 Managing patient flow
Operating Theatre Flow Model
08:00
08:30
09:00
09:30
10:00
10:30
11:00
11:30
12:00
12:30
13:00
13:30
14:00
14:30
15:00
15:30
16:00
16:30
17:00
1
2
3
4
which is a consultant
operating on a patient.
What is currently being
done in theatre that could
be done elsewhere? Can
tasks be undertaken in
parallel?
5
7. What is possible?
6
7
8
Anaesthetic
Operation
Post-Anaesthetic
Recovery
Figure 36. Actual flow utilisation
In the example above, there were seven
patients operated on. The total time in
theatre (excluding the time in recovery)
was 7hr 42min (from 0830 to 1612). The
total time a patient was being operated
on was 2hr 56min (the total length of the
“red” bars) or 38% of the total theatre
time.
It is possible to put
together an “ideal” flow
model scheduling around
the constraint. Use
estimated time for each
stage based on the 80th
percentile time for each step of the
process. This will make it possible to
estimate the optimum use of the
constraint and give a target to the
improvement project. Figure 37 shows
that should be possible to double the
number of operations.
Conclusion
5. Ask Why...
Over the course of the theatre day,
operations took up 38% of the available
time (actually even less, because the
session ended 18 minutes early). This is
not a good utilisation of a very expensive
resource. Why are there long periods when
there is no surgery taking place? What else
is happening during this time? In one case,
the delays were caused by the surgeon
leaving the theatre to fetch the next
patient
from
the
preoperative lounge —
because the theatre
management had “saved
money” by reducing the
number of porters.
08:30
09:00
09:30
10:00
10:30
This analysis tool will not show what
should be done, or even what the causes
of the delays are. Process mapping will
provide that information. The tool will
show how well scarce resources are used,
and how much room there is for
improvement.
Operating Theatre Ideal Flow Model
11:00
11:30
12:00
12:30
13:00
13:30
14:00
14:30
15:00
15:30
16:00
16:30
17:00
17:30
1
2
3
4
5
6
6. Ask How...
How can the situation be
improved? It should be
possible to schedule the
theatre in such a way so
as to maximise the use of
the scarce resource,
7
8
9
10
11
12
13
14
Anaesthetic
Operation
Post-Anaesthetic
Recovery
Figure 37. The “ideal” flow
Page 88
A guide to good practice
Chapter 5
Analysis tools
This chapter covers a number of additional analysis tools and procedures
that Trusts have found helpful in managing waiting lists. Access to good
information, and understanding the meaning of that information, is
essential if the NHS is to manage waiting lists effectively.
These tools should be considered additional to the three essential tools
in chapter 4, (activity-backlog-capacity-demand monitoring, process
mapping, flow modelling) which are fundamental to understanding services
in the NHS.
Understanding Demand
Understanding theatre use
This section looks at the relationship of
demand to activity and the importance
of monitoring demand and analysing
changes in demand.
Performance in theatres is critical to
improvement of elective processes.
Theatre resource is one of the most
expensive within a trust, and Innovations
in Care recommends the Modernisation
Agency Step Guide as a means of
monitoring theatre performance.
Carve out: Understanding queues
The NHS sometimes seems to be primarily
about queues rather than care. Patient
experience is often about waiting, and has
been described as long periods of waiting
broken by short periods of activity.
Understanding the principles behind
queue management will reduce queues
and improve waiting times.
Key performance indicators:
What should we monitor?
Knowing what to look for when monitoring
clinic performance is essential to getting
performance improvement. Innovations in
Care recommends the use of the CPaT
toolkit for monitoring the performance of
waiting times.
A guide to good practice
Measuring follow-up demand
Follow-up patients in outpatients are one
of the main demands on clinic time. But
before reducing demand, it is important
to understand it, and measuring followup demand for outpatient space is
difficult.
Statistical Process Control
Of the tools available to managers,
statistical process control is one of the
most useful in a wide variety of applications. From bed use to waiting times,
from referral to progress through a care
pathway, SPC provides a set of tools to
analyse performance.
Page 89
5.0 Analysis tools
Team working
Bro Morgannwg NHS Trust
Within Bridgend, therapists provided allocated sessions to each
of the funded Speech and Language resources based within
mainstream primary schools.
The Speech & Language Therapy Service had difficulties with
recruitment and retention of therapists. Therapists felt
isolated, and if a post became vacant an inequality of service
across locations resulted. The service was unable to meet
demand.
Additional recurrent funding from the LHB enabled a rotation
package to be established. Qualified therapists now work as a
team across the targeted resources, up dating assessments,
jointly agreeing Speech and Language Therapy targets with
school staff and other care-givers and preparing programmes.
Each resourced class has additional support from a Speech
and Language Therapy Assistant who is able to follow through
on tasks set by the therapist for continued direct work.
The outcome of an Audit questionnaire has shown the benefits
of this initiative. Therapists no longer feel they work in
isolation and are able to support each other clinically . Each
school location has received a therapy package of care based
on the needs of the individual children within the current
level of funding. The Assistant has provided a vital and
continuous link between the school and therapy services.
Page 90
A guide to good practice
5.1 Understanding demand
Understanding demand
Understanding the demand for services, and how it balances against the
activity the system is producing, is fundamental in understanding where
waiting lists come from and how to deal with them. This section addresses
issues of activity levels, changing demand, and how to relate one to the
other.
Demand and Activity
ional line represents the cumulative
difference between the inflow and the
outflow to the system — the backlog. It
can be seen at once that despite
significant variations from month to
month, the clinic in speciality A is in
Many analyses of outpatient problems look
at the waiting time, or the number of
patients waiting. While these are
important measures, they are symptoms
of a deeper problem. Understanding this
deeper problem is essential to
any attempt to address
outpatient performance.
Absolutely the first information
required relates to clinic
inflows and outflows.
Demand and Activity, Speciality "A"
600
500
Patient Numbers
400
300
Figures 38a and 38b show two
typical outpatient clinics. The
number of referrals for each
month is shown (Demand), as
is the number of patients seen
in clinic (Activity). It is obvious
that there is variation in both Figure 38a. Speciality A demand and activity
the demand and in activity. The
variation is small, and the
difference between demand
and activity is also small. On
their own these graphs are not
particularly meaningful. It is
necessary to extract the
difference between referral
and appointments to see the
true impact of a relatively
small imbalance.
200
100
Jan
Feb
Mar
Apr
May
Jun
Jul
Feb
Mar
Apr
May
Jun
Jul
Dec
Jan
Oct
Nov
Sep
Jul
Aug
Jun
Apr
May
Mar
Jan
Feb
0
Month
Demand
Activity
Demand and Activity, Speciality "B"
600
500
Patient Numbers
400
300
200
100
Dec
Nov
Oct
Sep
Jul
Aug
Jun
Apr
May
Mar
Feb
Jan
0
Month
Demand
Activity
Figures 38c and 38d extract
Figure 38b. Speciality B demand and activity
that information. The additA guide to good practice
Page 91
5.1 Understanding demand
Demand and Activity, Speciality "A",
with Backlog
600
500
400
Patient Numbers
300
200
100
Jul
Jun
May
Apr
Mar
Feb
Jan
Dec
Oct
Nov
Sep
Jul
Aug
Jun
Apr
May
Mar
Jan
0
Feb
balance. The variation is
around a horizontal line — the
backlog remains relatively
stable. Figure 38d (Speciality B)
tells a different story. There the
trend of the line is definitely
upward. There are some
months where the line dips
(possibly due to seasonal
variations), but over time, the
line creeps up. This speciality
is in trouble and the backlog
(waiting list) is increasing.
-100
-200
Month
Demand
Activity
Backlog
Figure 38c. Speciality A demand, activity and backlog
Demand and Activity, Speciality "B",
with Backlog
Waiting lists are like water in a
bath. As long as the water is
running out of the drain as fast
as the water is flowing in from
the taps, the bath will neither
overflow nor empty. The size of
the bath doesn’t matter — only
the rate of the flow in
(demand) and flow out
(activity). Like the waiting list,
the catastrophe occurs when
the inflow is greater than the
outflow — and the bath Figure 38d. Speciality B demand, activity and backlog
overflows.
The third possibility is that demand is less
500
400
Patient Numbers
300
200
100
Jul
Jun
May
Apr
Mar
Feb
Jan
Dec
Nov
Oct
Sep
Aug
Jul
Jun
May
Apr
Mar
Jan
Feb
0
-100
Month
Demand
There are three possible states for any
dynamic system such as this. In the first,
demand is greater than activity. Over
time, waiting lists will increase and
waiting times will get longer.
The second possibility is that demand and
activity are in balance. This may still not
be the ideal situation, because it is
possible that the system is in balance, but
with a large waiting list of patients in the
system. There is a perception that the
problem is unmanageable, because there
is a huge waiting list — but in fact this
situation is far more manageable than the
first, because one-off initiatives will have
a lasting effect, whereas they will not
resolve the first case.
Page 92
Activity
Backlog
than activity. This may seem a better
situation to be in (especially if there are
large waiting lists) because over time the
waiting list will reduce. But as with the
slowly draining bath, the situation is no
more sustainable in the long term than
the first case. In time, the waiting list will
disappear, and there will not be enough
work to maintain current staffing levels.
Is it possible to get the system in balance?
If a speciality has greater demand than
activity, there are only two ways to resolve
the problem. Permanent increase in
activity (one-off initiatives will only delay
the day of reckoning) or permanent
initiatives to reduce demand. Chapter 6
addresses the issue of referral guidelines
using priority setting at the GP practice,
and this is a good solution to reduce
demand. In general, there are many
referrals into secondary care that could
A guide to good practice
5.1 Understanding demand
Changes in demand over time
be handled in ways other than a
consultant outpatient appointment, and
each of these represents a waste of
resources.
Even if demand is in balance with activity,
there is still the risk that it will change
over time. Figures 39a and 39b show the
number of referrals per month for the past
18 months in two specialities. Figure 39a
shows a speciality where the demand is
stable or even dropping slowly. It is
important to realise that in this case,
reducing demand does not mean that
there is no problem or waiting list. The
speciality may still have an increasing
waiting list — because there is less activity
than demand.
Even if the system is in balance, referral
guidelines may still be a good idea. The
size of the waiting list is in itself a factor
in determining referral rates. If waiting
times are long, patients will seek other
options for treatment and GPs will be less
likely to refer. When waiting times reduce
(as a result of increased capacity or a oneoff initiative) there is less incentive to
treat patients, and more incentive to
refer into secondary care. Having referral
guidelines in place before undertaking the
volume reduction initiative will prevent
the surge in referrals, and preserve the
effect of the extra capacity.
Activity is not
capacity
Figure 39a shows a different problem.
Since February, the numbers of referrals
in this speciality are up on the previous
year, despite the seasonal variation.
Identifying specialities where the demand
Referral rates
Speciality "A"
600
Chapter 4 has already
dealt with the differences
between activity and
capacity, and the issues
associated with measuring
them. Activity is the rate
at which patients flow out
of the system — off the
outpatient waiting list,
off the inpatient waiting
list. Capacity is only the
same as activity when the Figure 39a. Trends in referrals, speciality A
whole system is operating
Referral rates
at 100% efficiency — and
Speciality "B"
experience shows that
this is rarely the case.
Capacity is the ability to
do work. It is a
combination of the
resources available and
the time that those
resources can be used.
500
Referrals
400
300
200
100
Mar
Apr
May
Jun
Mar
Apr
May
Jun
Jul
Feb
Feb
Jan
Dec
Nov
Oct
Sep
Aug
0
month
600
500
Referrals
400
300
200
100
Jul
Jan
Dec
Nov
Oct
Sep
Aug
0
month
Figure 39b. Trends in referrals, speciality B
A guide to good practice
Page 93
5.1 Understanding demand
is increasing is important in determining
what the long term activity will need to
be — and how it will need to change over
time. Balancing activity and demand
today is not going to provide a long term
solution because if referral rates continue
to increase, the demand will eventually
outstrip activity again. The solution is to
understand why the demand is increasing,
and address that problem.
Seasonal variation
Are referral rates stable across the year?
In some clinics, referrals increase at
certain times — typically medicine
referrals increase in winter, as do those
for orthopaedics. Referrals in dermatology
increase in summer. Some specialities
such as ophthalmology do not have
obvious trends. Seasonal trends are
important as they can skew the analysis
— if you do not look at the whole year, is
the increase you have detected a real
increase, or is it due to a summer bulge?
When looking at long term trends it is
useful to compare years on the same
graph, so that changes between months
can be seperated from the year to year
changes. An example can be found in
figure 40, where waiting lists for several
years are compared. Note that the newest
line is stable — compared to an upward
slope for the same months of previous
years.
Conversion ratios
It is important to treat the elective
process as an integrated whole. Increased
activity at outpatient clinics may affect
the flow on to the surgical waiting list,
but simple conversion ratios may not give
accurate predictions of future surgical
demand.
With long waiting lists, an initiative clinic
to remove patients from the tail of the
waiting list where primary targeting lists
have not previously been used, may
deliver lower conversion ratios due to the
nature of the patients who tend to
accumulate at the end of waiting lists.
Conversely, pre-screening of orthopaedic
referrals by a physiotherapist may
considerably reduce the number of new
referrals onto the consultant outpatient
waiting list. However, if the consultant
continues to see the same number of
outpatients, the ratio requiring surgery
and thus the number flowing onto the
inpatient waiting list, will increase
substantially as those patients unlikely to
proceed to surgery have been screened
out.
Number of patients waiting over 18 months
18000
16000
14000
12000
99/00
00/01
10000
01/02
02/03
03/04
8000
6000
4000
2000
March
February
January
December
November
October
September
August
July
June
May
April
0
Month
Figure 40. The waiting list compared year on year.
Page 94
A guide to good practice
5.2 Carve-out: Understanding queues
Carve out:
Understanding queues
“Carve out” is an insidious process that steals capacity before our eyes,
while appearing to protect the capacity for those patients who need it. In
complex processes like health, some carve out is inevitable, but it must
be eliminated where it can be, and managed where it cannot.
What is carve out?
Carve out is a term given to circumstances
where reserving some of a resource for
one group reduces the resource available
to another group. Carve out is seen every
day. It is present in supermarket car parks
(parent with child parking), in the
supermarket itself (basket only queues),
on the road (bus lanes) and in health.
Health is the natural home of carve out —
the NHS has adopted it as a solution to a
problem, and in doing so created an even
bigger problem.
How many queues are there?
In a typical outpatient clinic there are
probably hundreds of queues. There are
slots for new patients, there are slots for
urgent new patients. There are
postoperation slots and there are soon
review slots. In some clinics the number
of slots can run well into two digits. These
slots are created in an attempt to balance
out the capacity to match the patients
coming through the clinic, but it is an
endeavour doomed from the start. There
is a very simple reason.
That many queues cannot be managed.
The odds that every week (or any week
for that matter) the exact proportion of
patients will match the available slots are
A guide to good practice
minute. What happens instead is that
there are empty slots, then the clinic is
overbooked to fit the extra patients in.
The schedule goes out of the window, and
the flow of work is totally disrupted.
Banks worked this out some time ago: they
have a single queue, feeding into multiple
windows. The days when you joined one
of multiple queues at the Post Office and
cursed because the others were always
moving faster are long gone.
What is the impact of carve-out?
Carve out wastes capacity. Figure 41 over
the page represents an outpatient clinic
with a high degree of carve out — separate
slots for each patient type, different
clinics for different conditions. The
waiting list is represented by the upper
line (circles). The lower thick line (solid
squares) shows what the waiting list would
have been if each patient was booked into
the next available slot instead of the
allocated speciality slot.
Dealing with carve out
Some carve out is necessary and has
benefits in spite of the negative impact
on waiting times. Two such examples are
carve out to reserve space for urgent
patients in partial booking, and carve out
to allow clinical subspecialisation. The
Page 95
5.2 Carve-out: Understanding queues
important thing is to allow
the benefits and manage the
carve out to minimise its
effects.
Rheumatology comparison between Generic and Specialist Clinics
Capacity vs Demand
100
90
80
70
Dealing with the 10 day
waits
Partial booking allocates
patients to clinics about four
weeks
before
the
appointment. There is a
need to reserve some
capacity for those patients
that the Trust does not know Figure 41. With and without carve out
about four weeks from the
clinic.
Hours work
60
50
40
30
20
10
0
Sep-00
Oct-00
Nov-00
Dec-00
Jan-01
Feb-01
Mar-01
Apr-01
May-01
Jun-01
Jul-01
Aug-01
Sep-01
Month
Capacity
As described on page 59 there are ways
of managing this carve out so that it does
not affect the waiting times for non-10
day patients. The key to resolving carve
out in this case is to manage the impact
of carve out.
Managing subspecialisation
The section on pooling in waiting lists gives
methods that allow Trusts to deal with
carve out caused by subspecialisation.
Subspecialisation has benefits in
improving skill mix in specialist areas. The
carve out caused by subspecialisation
must be managed, rather than trying to
prevent it.
Demand
Capacity b acklog with generic b ooking
Capacity b acklog with carveout b ooking
to managing carve out caused by
prioritisation; prioritise a single list of
patients, and then allocate those patients
from the top of the list into nondifferentiated slots in the clinic. “Urgent”
patients do not go into “urgent” slots;
“soon” patients do not go into “soon” slots
and “routine” patients are not booked into
“routine” slots. Instead all “urgent”,
“soon” and “routine” patients are booked
into generic outpatient slots.
Prioritisation and carve out
Accepting clinical prioritisation does not
mean allocating carved out slots to each
category of prioritisation. This is the key
Page 96
Urgent
Prioritised List
It is important to distinguish between
clinical prioritisation and carve out. While
there are issues with the type of
prioritisation used, if waiting lists are
longer than a few weeks, some degree of
prioritisation will be essential. The degree
of prioritisation should be minimised, so
that as few categories are used as are
required to meet the need to see patients
within clinical priority.
Activity
2
week
slots
See in
2
weeks
Soon
Generic
slots
Routine
Figure 42. From a prioritised list to generic slots
A guide to good practice
5.3 KPIs: What should we monitor?
Key performance indicators:
What should be monitored?
No system works so well that you can assume it will work from day one,
and continue to work. Ongoing monitoring and feedback to staff is as
essential to the success of the improvement process as work going into
the initial setup. There are a number of factors that must be carefully
watched if the long term success of booking is to be maintained. These
are Key Performance Indicators (KPIs).
Outpatient KPIs
Could not attend (CNA) delays
It is useful as a performance measure to
be able to see what notice you are getting
of CNAs. If CNAs are dated in the PAS, it is
possible to report on the proportion of
cancellations that are on the day of
appointment or surgery (these
appointments cannot be reused by
another patient) as compared to those
made early enough that the appointment
time can be reused. This also allows you
to compare the number of appointments
or theatre minutes lost which were as a
result of patient cancellations more than
24 hours in advance (pointing you to work
on improving the short notice booking
mechanisms in the appointment centre).
DNA Rates and cancellation rates
Regular (at least monthly) reporting on
DNA rates and both patient and hospital
cancellation rates is a must. This is the
information required to convince staff
that any new system works. It is important
to flag those patients booked through the
old system, and compare the rates to
those managed through the new, in order
to highlight the differences in those clinics
where not every patient is booked.
A guide to good practice
How far ahead are we booking?
The time to the currently allocated phone
date is vital information about potential
workload. If your PAS calculates this
information as is the case in our pilot,
weekly reports by clinic enable you to see
where wait times are getting longer or
shorter, a simple and effective measure
to assist in calculating capacity issues.
Are patients booked in 4 weeks?
Some Trust outpatient systems may not
be able to implement the method for
booking follow-up patients recommended
in chapter 3. If your system cannot be
adapted, you will need to introduce KPIs
to allow the monitoring of follow-up
booking.
If the system sends “phone now” letters
4 weeks prior to the original estimated
appointment, weekly monitoring of the
available slots is vital. We suggest a
“traffic light” system where you record
which appointment date a phone booking
is made.
If the appointments made in response to
phone calls are four weeks away, then the
clinic is in “Green” and the system is
performing well. There are two “Amber”
states. “Amber and increasing” at five
Page 97
5.3 KPIs: What should we monitor?
weeks means that there are more patients
phoning than there are appointment slots,
and the system must be watched closely
to determine if this is a statistical
fluctuation or a longer term trend. If it is
a trend, the number of slots for followup will need monitoring. If statistical, the
situation will right itself. Statistical
variation may be caused by a single
cancelled clinic.
starts and finishes will all help keep
control of this area.
In the “Amber and decreasing” state, once
again careful monitoring is in order. The
same questions arise as to whether the
decrease is statistical, or due to too few
patients for the clinic slots.
Elective waiting lists
“Red” states are more serious. At “Red
two weeks”, measures need to be taken
to: a) ensure that clinics are booked fully;
and b) determine whether this is a
worsening problem. If you have been
monitoring you will know this from the
work done during “Amber”, but now
action is needed, and a predetermined
course (bringing patients forward etc) put
in place.
“Red six weeks” is an issue of a different
sort. Action is needed here because we
can now no longer give patients certainty,
and urgent action is needed to pull the
booking back to under six weeks. Once
again, an action plan should be in place
to respond.
Are we cancelling patients?
An important measure is the number of
patients getting their appointment on the
date they originally negotiated. Related
to hospital cancellations, this measure
gives surety that the patient is getting the
service promised.
Smooth running of clinics
The promise to clinicians was that booking
would improve their quality of life in the
clinics. Hard evidence about over / under
booking, over / under run clinics, late
Page 98
Clinic profiles
Annual review of all clinic profiles, or
review whenever clinic procedures
change, is vital. A system needs to be in
place that monitors when each profile was
last updated and when it is due for review.
It is too easy for this to slip over time.
There are a number of tools which can be
used to monitor elective waiting lists. The
two most important are monitoring the
trends in numbers and waiting times, and
monitoring the way in which patients are
removed from the list for booking.
Trends in list performance
The monitoring of waiting lists, both in
terms of numbers waiting and the length
of waits, is best done through the use of
SPC charts (see page 105). SPC charts will
allow the detection of trends, and
distinguish between trends and random
variation. SPC charts for both the number
of patients on the list and the number of
patients waiting over a pre-set amount
of time (e.g. 12 months) are essential.
How are patients booked?
The biggest problem with managing
waiting lists is ensuring that the patients
are removed in strict date order according
to pre-determined clinical priority. There
are several approaches to this.
How long did patients wait?
Report on the length of time each patient
waited, and look at the distribution of
waits. If patients are being booked in turn,
all patients of the same clinical priority
will have similar waits.
How long are patients waiting?
What is the shape of the waiting list? If
patients are being taken in turn, it should
A guide to good practice
5.3 KPIs: What should we monitor?
have a level period followed by a steep
drop, rather than a steady drop over time.
The “Gwent” measure
Gwent NHS Trust monitor removals by
converting the waiting list to “days
waiting” and seeing how close the actual
number of days removed is to the
theoretical days that could have been
removed each month. This tool (described
on page 37) was developed for outpatient
monitoring, but would be applicable to
elective lists as well.
CPaT
The Modernisation Agency has put
together a set of tools for monitoring
waiting lists. See the box below.
Effective Use of Theatres
The Audit Commission in Wales Acute
Hospital Portfolio report states that in
Wales :
• Patients wait longer than those in
England to be admitted for routine
surgical treatment;
• There is strong evidence that when
more beds are available, more patients
The CPaT Toolkit
The Modernisation Agency
The Modernisation Agency in England has
produced a toolkit for monitoring waiting
lists. Called the Clinical Prioritise and Treat,
the step guide and toolkit allows detailed
analysis of waiting lists and waits by clinical
priority within waiting lists. CPaT is a
process as well as a set of tools, and there
are instructions on using the toolkit with
multidisciplinary teams as a way of reducing
waiting times.
Innovations in Care recommends the use of
this toolkit both as an initial analysis tool,
and for ongoing monitoring prurposes
The toolkit can be obtained from:
www.modern.nhs.uk/cpat
or contact Innovations in Care.
A guide to good practice
are placed on the waiting list;
• 10% patients have had their admission
cancelled within a week of a planned
operation;
• Only 70% of patients received their
operation within a month of the original
cancellation;
• There is variation in pre-assessment
practices;
• Published waiting time data do not
always reflect the full patient
experience.
It is recognised that Operating Theatre
time is one of the most expensive
resources that a trust has to manage and
it is an extremely complicated task to
ensure that all the correct equipment,
stores and staff are assembled in the same
place at the same time that the patient
needs them.
The publication of the Modernisation
Agency’s Step Guide to Improving
Operating Performance (2002) was the
culmination of an extensive project
involving nine pilot sites in England. The
project examined all aspects of Operating
Theatre provision and the tools
developed, along with the Step Guide
itself, offers straightforward, step by step
advice to improving theatre services.
Innovations in Care were involved in the
revising of the final draft of the document
and there was a recognition that the issues
identified were common to Wales and that
the solutions suggested would be as valid.
It was agreed to adopt the document as
the main reference document for the All
Wales Theatre Programme.
The Step Guide
Step 1: Planning & management
Trusts are encouraged to set up properly
agreed management structures that have
sufficient authority to make the decisions
necessary to ensure optimum use of
theatre capacity. Timely and accurate
Page 99
5.3 KPIs: What should we monitor?
information is key to informing the the importance of theatre management
decisions that must be made to ensure is underlined by nominating an Executive
optimum performance. This is reinforced Director to be responsible for theatre
in the Audit Commission Acute Hospital performance.
Portfolio report on Operating Theatres
(June 2003) that identified that
Step 2: Diagnosis & analysis
information is key to effective
The Theatre programme in Wales has
management of theatres. As in the Step
developed its own Key Performance
Guide, Innovations in Care recommends
Indicators that reflect the areas that
planning
and
management should
m a n a g e m e n t We recommend that trusts complete
have knowledge of
structures to support the Self Assessment Checklist that is
on
a
regular
effective planning included in the Step Guide.
(monthly) basis.
and management of
These indicators
operating theatre This will provide a baseline assessment
build
on
the
performance, includ- against the standard and will highlight
information already
ing implementation areas of compliance and non
submitted by trusts
of systems to report compliance from which trusts can
in the Cancelled
regularly on key target their improvement action
Operation data.
performance indic- plans.
Analysis of both will
ators.
identify key areas for
trusts to focus their efforts on to ensure
The first section of the guide also covers: improvement to the service. An example
of the type of outcome chart is shown in
· Actions for NHS Trust Boards.
figure 43.
· The role and membership of the
Theatre Management Group.
The sharing of this information between
· Theatre policy documents.
Trusts has allowed benchmarking and
identification of areas of good practice
· Examples of effective practice.
and it is recommended that trusts
continue to meet with each other on a
One of the key recommendations is that
regular basis to
ensure the continAllocation & Utilisation of Operating Hours
uation of this
‘shared learning’.
Agreed All Wales
%
110
100
90
80
70
60
50
40
30
targets
27
23
92%
11
88%
25
unused hours
73
77
89
utilised hours
75
20
10
0
Total planned
Total
time (hrs)
allocated time
(hrs)
Total
AVAILABLE
used time
(hrs)
Total ACTUAL
used time
(hrs)
Figure 43. Example of graph showing utilisation of operating hours
Page 100
The Step Guide also
contains diagnostic
tools that examine
the patient experience and staff
satisfaction.
Innovations in Care
recommends that
Trusts undertake
these surveys and
discuss the results
with colleagues
across Wales and in
England.
A guide to good practice
5.3 KPIs: What should we monitor?
Step 3: Improving operating theatre
performance
Where areas of concern are identified
Innovations in Care will provide training
in ‘Process Mapping’ techniques to enable
staff to highlight the bottlenecks and
constraints in a system and be able to
redesign the service using Plan Do Study
Act cycles to ensure measurable
improvement.
The Modernisation Agency step guide
divides this section into three key areas:
1. Patient experience;
2. Human Resources;
use of available information to ensure
theatre sessions are accurately planned.
Prospective lists should be published with
adequate time or early notification must
be given of special needs to ensure
theatres have the correct equipment
available.
Systems of work must be examined to
ensure that delays in patient transfers are
minimised.
Electronic copies of the following
documents are also available on
w w w. m o d e r n n h s . n h s . u k /
theatreprogramme
3. Elective & Emergency surgery.
It must be recognised when attempting
to improve Operating Theatre services
that some of the key impacts are often
outside the department. So it is vital that
all stakeholders in the Operating Theatre
services are identified and involved in any
improvement strategy. As with the other
sections of this guide it is recommended
that a whole system approach is taken
when making improvement.
Step 4: Scheduling
The main areas that affect effective use
of theatre time are scheduling and
internal arrangements for getting the
patient to the right theatre at the right
time. Effective pre-operative assessment
has a double effect on theatre efficiency
by ensuring that cancellations are
minimised and therefore ensuring that
utilisation is increased.
Overbooking of theatre sessions will have
a detrimental effect on cancellation
rates. It is the second most important
cause of cancellations due to non-clinical
reasons: in the first quarter of 2003, over
370 operations were cancelled due to list
over-runs. This is where effective and
timely scheduling is key. Surgeons and
theatre management teams must make
A guide to good practice
• Step Guide to Improving Operating
Performance
• Theatre programme diagnostic tools &
user manuals
• Audit Commission Theatre Kit
Conclusions
The purpose of key performance
indicators is to ensure that everything is
running smoothly. It is far easier to keep
on top of the problems than to fix them
later.
Do not be afraid of setting up too many
monitoring tools. It is easier to set up tools
to monitor more than you think will be
necessary and then to stop the ones that
are less use than to have to set up new
measures six months down the track
because the process has gone wrong.
Overmeasure at first, and pare down the
tools over time.
Avoid using KPIs as a way of imposing
performance targets. While KPIs can be
(and are) used this way, the real value of
KPIs is in allowing the staff in a service to
look at their performance and see what
is really happening.
Page 101
5.3 KPIs: What should we monitor?
Dermatology Nurse Specialists
Conwy & Denbighshire NHS Trust
As a result of the long waiting times in Dermatology,
Dermatology nurses within Conwy & Denbighshire NHS Trust
have developed their roles to relieve some of the demands
on the service.
A nurse-led acne clinic has been developed, seeing patients
directly from the waiting list, which has reduced the waiting
times from 18 months to 6 months within a 6-month period.
Those patients prescribed Roaccutane require close monitoring
and support. A nurse-led monitoring clinic has been
established which fulfils this need, allowing more time for
doctors to see patients from waiting lists.
SOS patients are given an access phone number for shortnotice appointments.
Teledermatology
Conwy & Denbighshire NHS Trust
To improve access to the service, a Dermatology nurse was
appointed in September 2002, with the focus of introducing
teledermatology to the Trust. Following an introductory
period of training, planning and developing protocols,
teledermatology clinics have been introduced to three
peripheral sites on a “store and forward” basis. Images are
viewed by a consultant Dermatologist, and the suspected skin
cancer referrals prioritised accordingly.
Initially, this has been used as a triage imaging assessment
tool of skin lesions, and not a substitute for consultation.
As a result, a nurse-led lesion-screening clinic has been
developed, allowing greater access to the specialty for routine
conditions, thus reducing waiting times by a quarter over the
last few months from 24 to less than 18 months, with a target
waiting time of 12 months by March 2004.
Page 102
A guide to good practice
5.4 Measuring follow-up demand
Measuring
follow-up demand
Many trusts and specialities have a problem with seeing outpatients at
short notice. In response to the need to fit patients into full clinics two or
less weeks into the future, Trusts have traditionally set aside appointment
slots or overbooked clinics at the last minute.
Percentage of patients follow-up appointments allocated
each period ENT
20%
15%
10%
5%
One way to understand what the demand
will be on future services is to
prospectively record every follow-up
appointment made for a time period
(preferably several months) and keep a
track of how many 1 week, 2 week, 3 week
etc. appointments are made each week.
An alternative is to estimate the demand
Proportion of Total Slots Full
CJN4A
Percentage of Appointments Filled
120%
m12
m11
m9
m10
m8
m7
m6
m5
m4
w13
w12
w11
w9
w10
w8
w7
w6
w5
w4
w3
w2
0%
w1
Typically, Trusts understand demand for
follow-up services even less than they
understand demand for new referral slots.
As a result, clinics are often overbooked
and capacity is often exceeded by
demand, leading to overcrowding and
reduction in new referral capacity. Even
where information about the number of
available appointment slots is available
when booking, one vital piece of
information is missed out: how many more
patients will be referred to that clinic
between now and the clinic happening?
based on historical data. By analysing all
the appointments made over an 18 month
period, and calculating the time between
the appointment and its predecessor, an
estimate of appointment frequency can
be made. For one ENT service, the
distribution is as follows:
Percent of slots needed each period
Understanding the workload.
Period
Figure 45. Number of weeks / months between
a followup being made and the appointment.
Note that 5% of appointments are made
for 1 week, 5% for 2 weeks, 5% for 3 weeks
etc. 25% of appointments are made for
less than 6 weeks. In order to leave room
for these patients, at 6 weeks the clinic
should be only 75% full. The clinic in figure
44 is already full for the next seven weeks.
Where will these patients be placed?
100%
80%
60%
40%
20%
Period
Percent filled
100%
Figure 44. A typical ENT clinic — no slots
available for the next seven weeks!
A guide to good practice
m12
m11
m9
m10
m8
m7
m6
m5
m4
w13
w12
w11
w9
w10
w8
w7
w6
w5
w4
w3
w2
w1
0%
There needs to be a way to look at clinics
and take account of the work that will
come in, not only the work that has
already come in. If that information is
made available to clinicians, then they
will be better able to make the decision
about when to bring patients back —
Page 103
5.4 Measuring follow-up demand
Step 3: Plot your “actuals”...
The jagged line represents the ENT clinic
seen overleaf. As can be seen, there are
times when it is above the boundary line
— the clinic is over full. There are also
times when the clinic is underfull for that
week or month.
Step 1: Plot the distribution...
90%
80%
70%
60%
50%
40%
30%
20%
10%
m12
m11
m9
m10
m8
m7
m6
m5
m4
w13
w12
w11
w9
w10
w8
w7
w5
w4
w3
w2
w1
0%
period
Percent filled
Percent free
CJN4A
allowed 100%
Figure 45c. Step 3
20%
Step 4: Simplify the
presentation...
Percent filled of "allowed" slots
CJN4A
200%
150%
100%
50%
m12
m11
m10
m9
m8
m7
m6
m5
m4
w13
w12
w11
w10
w9
w8
0%
w7
The lower area represents the proportion
of the clinic that should be filled, based
on the distribution in the first graph. The
upper area is the proportion needed to
deal with the appointments “yet to
come”. The boundary between the upper
and the lower is the proportion of the
clinic that should be filled at any time.
The boundary line represents “full” if
there is to be space available for any
appointments yet to come.
w6
Step 2: Convert to a cumulative
graph...
w5
Figure 45a. Step 1
w4
Period
w3
m12
m11
m9
m10
m8
m7
m6
m5
m4
w13
w12
w11
w9
w10
w8
w7
w6
w5
w4
w3
w2
0%
The last graph “flattens” the boundary
line, setting it as “100%”. The jagged line
becomes the series of vertical bars,
showing over and underbooking against
the new profile. This graph could be given
to consultants or clinic staff to show
where problems are predicted. Compare
this graph for the clinic to figure 44.
w2
5%
w1
10%
percent filled
15%
w1
Percent of slots needed each period
Percentage of patients follow-up appointments allocated
each period ENT
Percent filled / free ENT
(with CJN4A)
100%
Percent of clinic filled
Use as long a time frame as possible —
the shorter the time you choose, the more
under-represented the longer appointments will be, as either the first or the
second appointment will be missing from
the sample. Use a sample size of 18
months; more would be better!
w6
balancing clinical need with clinic
availability. This can then be combined
with a partial booking process for followup patients to reduce the last-minute
overbooking and cancellation that is
common today.
period
% filled of allowed
100%
Figure 45d. Step 4
Understanding demand for follow-up
appointments will assist booking, and it
will go a long way to improving the current
chronic overbooking found in many clinics.
m12
m11
m10
m9
m8
m7
m6
m5
m4
w13
w12
w11
w9
w10
w8
w7
w6
w5
w4
w3
w2
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
w1
Percent of clinic filled
Percent filled / free ENT
period
Percent filled
Percent free
allowed 100%
Figure 45b. Step 2
Page 104
A guide to good practice
5.5 Statistical Process Control
Statistical
Process Control
Statistical Process Control (SPC) can help in virtually all aspects of managing
healthcare. From monitoring of waiting times for a Trust to monitoring
prescribing on a ward, SPC provides a way of separating the “information”
from the “noise” so that managers and clinicians can understand what is
going on. Too often decisions are made without knowing whether changes
in data are due to actions taken, or merely due to chance.
The time has come to reclaim the benefits
of this methodology and use the tools to
understand and monitor the work we do
on a daily basis. To help in this, this section
abandons the nomenclature traditionally
used in statistical process control methodology. To assist those who are familiar
with the older jargon, there is a short
glossary on the next page.
Ignoring time:
The curse of the monthly report
Most healthcare organisations manage
through monthly reporting. These reports
present data for the past month (often
several weeks after the end of the time
period) and probably a year to date
position, including a target.
Unfortunately, a monthly progress report
shows little about the future. Indeed,
managing by the monthly report has been
likened to driving a car by watching the
road in the rear view mirror. To manage
future events, you must predict the
future. The best approach to prediction
is analysis of past trends.
The best way to display trends in data is
the run chart — plotting weekly or
monthly values as a time sequence. Run
charts are a significant improvement over
A guide to good practice
traditional reporting techniques, because
they introduce the concept of changes
over time.
Unfortunately, in order to manage a trend,
it is necessary to go one step further. Is
the change in the run chart due to a
change in the process, or is it simply due
to random fluctuation. To do this the trend
must be separated from the noise
resulting from random variation. Much
damage can be done by assuming a
monthly change is the break in a trend,
or represents a change resulting from
action taken last month, when in fact it
represents the effect of routine variation
caused by random factors. This is where
process behaviour charts come in.
The process behaviour chart
Process behaviour charts are a type of run
chart. The aim of a run chart is to look
for changes in performance over time. The
aim of a process behaviour chart is to show
whether the changes seen in the run chart
are as a result of routine variation in the
process, or the result of exceptional
variation, indications that something in
the process has changed. From the
separation of routine and exceptional
variation it is possible to determine
whether the changes in data represent
Page 105
5.5 Statistical Process Control
changes in performance or simply the
normal variability of the system.
Figure 47 on the next page illustrates this
problem. It is a run chart showing the time
sequence from April 2000 to March 2001,
and the number of patients waiting over
18 months for an outpatient appointment.
The graph shows a drop in March, which
is against the trend for the previous year.
Does this drop represent a real change, a
one off event, or random variation?
It is difficult to see
changes in the
trends in figure 47.
They can be made
clearer by plotting
the change from
month to month,
rather than the
actual values. This
has been done in
figure
48.
A
constant trend will
now be shown as a
horizontal line, and
the difficulty of
estimating changes
in
slope
are
removed.
Creating the process behaviour chart
To convert this run chart to a process
behaviour chart, some calculations are
necessary, and some information must be
added.
1. Calculate the average change. Exclude
the March 2001 data from the averaging
process as the purpose is to see if this
is outside the normal range. The
average line (shown on figure 49 as the
dotted line) is therefore the average
of the values from May 2000 to February
2001.
We have adopted most of the recommendations
of Donald J Wheeler in this section*
Instead of control chart we use process behaviour
chart.
Instead of in control process we use predictable
process.
Instead of out of control process we use
unpredictable process.
Instead of an in control point we use a point inside
the limits.
Instead of an out of control point we use a point
outside the limits.
Instead of control limits we use natural process
limits.
Instead of common cause variation we use routine
variation.
Instead of special cause variation we use
exceptional variation.
2. Calculate the
average moving
range (AMR). This is
the
difference
between each value
and the next. If the
difference is a
negative number,
ignore the sign. In
this example the
AMR is 150.
3. Multiply the AMR
by 2.66 (150 X 2.66
= 400). 2.66 is a
constant, derived
for this purpose.
Figure 48 shows
that the change in We have chosen to remain with Statistical Process 4.
The
upper
Control (SPC) rather than Wheeler’s Methods of
numbers waiting Continual Improvement because we feel the term natural process
from month to too encompassing of other tools used in quality limit is the value
month does vary improvement.
from step 3 added
between -200 and
to the average (206
+450, and it also shows that March 2001
+ 400 = 606).
represents the first point at which there
is a negative value — a reduction in the
waiting list. Is this reduction real, or 5. The lower natural process limit is the
value from step 3 subtracted from the
simply random fluctuation? The answer
average (206 - 400 = -194).
can be provided by converting the run
chart to a process behaviour chart.
These limits can now be plotted on figure
49. They are represented as the dashed
lines.
*
Donald J Wheeler. Understanding variation: The
Key to Managing Chaos (2nd edition).
Page 106
A guide to good practice
5.5 Statistical Process Control
The natural process limits represent the
range within which the process can
expected to vary. Any variation outside
these limits will indicate that the process
has in some way changed.
on figure 50. This indicates that these two
months represent a change in the process.
Something has led to an increase in the
rate at which the number of over 18
month waits is growing. But when did the
increased trend start? Was it in September,
Interpretation of the
process behaviour
chart
The natural process limits
represent the range
within which variation is
routine. If a point falls
outside those limits, it is
due to exceptional causes
— either to some one-off
exceptional event, or a
change in the process in
some way. When the data
fall outside the range
FIgure 47: The run chart of numbers waiting
shown on the charts, you
will know that something
Monthly change, Over 18 month waits
has been done that has
affected the number of
long waiting patients.
N u m be r w aitin g o ver 18 m o n th s
70 00
60 00
50 00
40 00
30 00
20 00
10 00
Oct-01
Sep-01
Aug-01
Jul-01
Jun-01
May-01
Apr-01
Mar-01
Feb-01
Jan-01
Dec-00
Nov-00
Oct-00
Sep-00
Aug-00
Jul-00
Jun-00
Apr-00
May-00
0
P a tie nts W a iting
700
600
500
400
The March 2001 value,
while low and the first
reduction seen, does not
fall outside the natural
process limits. While the
reduction may be due to
extra end of year work,
there is no reason to put
the reduction down to Figure 48: The run chart of change from month to month
anything other than
Monthly change, Over 18 month waits
routine variation within
the process.
300
200
100
Oct-01
Aug-01
Aug-01
Oct-01
Jul-01
Jul-01
Sep-01
Jun-01
Jun-01
Sep-01
May-01
Apr-01
Apr-01
May-01
Mar-01
Mar-01
Feb-01
Jan-01
Dec-00
Nov-00
Oct-00
Sep-00
Aug-00
Jul-00
Jun-00
-100
May-00
0
-200
-300
Monthly change
700
600
500
400
300
200
100
Both September and
October 2001 are outside
the natural process limits
A guide to good practice
Feb-01
Jan-01
Dec-00
Nov-00
Oct-00
Sep-00
Aug-00
Jul-00
-100
Jun-00
0
May-00
Extending the series
What happens if we
extend the graph? On
Figure 50, data through to
October 2001 has been
added.
-200
-300
Monthly change
Average
Upper Natural Process Limit
Lower Natural Process Limit
Figure 49: The process behaviour chart of change month to month
Page 107
5.5 Statistical Process Control
or was it earlier and took
until September to
exceed the limits?
Monthly change, Over 18 month waits
800
700
600
500
400
300
200
100
Oct-01
Sep-01
Aug-01
Jul-01
Jun-01
May-01
Apr-01
Mar-01
Feb-01
Jan-01
Dec-00
Nov-00
Oct-00
Sep-00
Aug-00
Jul-00
-100
Jun-00
0
May-00
There are three tests of a
change in behaviour in a
process behaviour chart.
Each of these tests
indicates that something
outside the normal course
of variation has occurred.
-200
1. The appearance of a
point outside the natural Figure 50: The process behaviour chart extended to October 2001
process limits has already
Number waiting over 18 months
been covered. A single
point (rather than a series
of points) outside the
range could represent a
one-off
exceptional
variation, due to either a
change in the process or
an outside cause that
affected only that month.
A single point should
therefore be regarded
with caution as an
indication that the
process
has
been Figure 51: The run chart extended to October 2001
changed.
earlier than September 01 when the first
2. A run of eight or more points on one point is outside the upper natural process
side of the average line. In figure 50, all limit. It indicates that there has been a
the points from April 2001 are on the upper change in the process in place since
side of the average, and if the November around May 2001.
Monthly change
Average
Upper Natural Process Limit
Lower Natural Process Limit
10000
9000
8000
7000
6000
5000
4000
3000
2000
1000
Oct-01
Sep-01
Aug-01
Jul-01
Jun-01
May-01
Apr-01
Mar-01
Feb-01
Jan-01
Dec-00
Nov-00
Oct-00
Sep-00
Aug-00
Jul-00
Jun-00
May-00
Apr-00
0
Patients Waiting
data was also above 206 this would satisfy
the test that a change existed from April
2001. At present it does not. This test will
pick up relatively small changes in the
trend, but it needs a long period (8 time
intervals) to show up.
3. Three of four consecutive points are
closer to the one of the natural process
limits than the average. On figure 50, May
01, July 01 and August 01 are all closer to
the upper natural process limit than the
average. This test has been met, and
indicates a change in the process from
Page 108
Figure 51 extends figure 47 over the same
date range, and shows that the slope on
the chart from March 2001 is steeper than
prior to that date. This supports the
proposition that something has changed
across Wales since April 2001, but the
process behaviour charts confirm the
significance of the change.
It would be possible to generate the
process behaviour chart on the raw data
in figure 47. To do this, as there is a trend
upwards in the data, the average line
A guide to good practice
5.5 Statistical Process Control
Over 18 month All Wales XmR chart
20,000
18,000
16,000
14,000
12,000
10,000
8,000
6,000
4,000
2,000
Over_18
mean
Upper NPL
Mar-04
Jan-04
Feb-04
Dec-03
Oct-03
Nov-03
Sep-03
Jul-03
Aug-03
Jun-03
Apr-03
May-03
Mar-03
Jan-03
Feb-03
Dec-02
Oct-02
Nov-02
Sep-02
Jul-02
Aug-02
Jun-02
Apr-02
May-02
Mar-02
Jan-02
Feb-02
Dec-01
Oct-01
Nov-01
Sep-01
Jul-01
Aug-01
Jun-01
Apr-01
May-01
Mar-01
-
Lower NPL
Figure 52. A more complex process behaviour chart, showing different stages in a process, with
the upper and lower limits recalculated after a major change in the process behaviour. This
chart also shows a sloping set of process limit lines
More importantly, process behaviour
charts can be used to analyse and monitor
changes made as part of an improvement
process. As part of the PDSA cycle (change
through experimentation) process
behaviour charts can be set up to monitor
the processes that are being changed. It
will then be possible
to
determine
Wheeler’s principles for
whether a change to
understanding data
Use of process
the process (as part
First principle:
behaviour charts
of a Plan Do Study
Process behaviour No data have meaning apart from their Act cycle) has in
charts are used to context
fact led to a change
separate
the
in the performance
Second principle:
“noise” from the
While every data set contains noise, some of the process.
“information” in a
using
data sets contain signals. Therefore, Without
data series. They
before you can detect a signal within a process behaviour
can be used to
data set, you must first filter out the charts to monitor
analyse trends and
performance of the
noise.
make
reliable
Plan Do Study Act
predictions about
cycle it will not be
the future. They can also be used to possible to determine accurately whether
monitor performance and determine the outcome is a result of the change, or
whether performance changes are real simply the effect of variation.
or simply an artifact of the variation in
the system.
needs to incorporate the steady state
increase. This can be done by creating an
“average” line that is a “best fit” and
calculating the natural process limits
either side of the best fit line. Although
this is possible (see March 01 to September
02 in figure 52) it is
more complicated.
A guide to good practice
Page 109
5.5 Statistical Process Control
One stop clinics: Office gynaecology
Conwy & Denbighshire NHS Trust
As a result of the long inpatient and outpatient waiting times
in Gynaecology, the Obstetric and Gynaecology Directorate
within the Conwy and Denbighshire NHS Trust have expanded
the One Stop Clinic to reduce the waiting list times.
The main aims of the One Stop Clinic are as follows :
• Investigation and management of postmenopausal bleeding
• Investigation and management of menorrhagia
• Investigation of female urinary incontinence
The clinic is run every Monday and every other Thursday and
led by a Consultant Obstetrician and Gynaecologist. This
consultant currently runs a rapid access postmenopausal
bleeding clinic, other “see and treat” procedures carried out
within the One Stop Clinic are :
•
Hysteroscopies
•
Biopsies
•
Scans
•
Insertion of Mirena coils
With the successful introduction of the One Stop Clinic waiting
lists have been reduced dramatically over the past twelve
months, thus reducing pressure on the Service. Future aims
are to double the capacity for combined colposcopy and
hysteroscopy procedures.
Page 110
A guide to good practice
Chapter 6
Managing
change
The previous two chapters have covered analysis tools. But analysis is not
enough. Analysis without action is an academic exercise. This chapter
covers some basic tools for implementation of change.
The human dimensions
Change happens when people want
change to happen. Taking the staff and
patients along with you on the change
process is essential.
PDSA cycles: A model for
improvement
The use of PDSA cycles as a mechanism
for delivering change has revolutionised
the change process in England, Wales and
the United States where the technique
was first developed.
Reducing follow-up demand
The follow-up patient is a major source
of demand on outpatient clinics.
Understanding what happens in clinics and
then making changes to reduce follow-ups
is a major source of additional outpatient
capacity.
GP feedback systems
The use of access protocols in primary
care is a common way of trying to reduce
demand on secondary care services.
Innovations in Care recommends an
alternative to access protocols, the use
of active feedback to GPs.
A guide to good practice
Using “Plan Do Study Act”
cycles in Endoscopy
Cardiff and Vale NHS Trust
Demand and Capacity principles are being
applied to Endoscopy services at the
University Hospital of Wales. Detailed
process-mapping at multi-disciplinary
workshops identified opportunities to
improve patient preparation prior to the
endoscopy examination as a means of
increasing the number of patients who
attend.
The team planned a PDSA cycle by selecting
an Endoscopy list for non-urgent patients,
and training a senior nurse to carry out
telephone pre-admission assessment of
patients. Data collected included changes
in patient attendance rates and the time
taken to assess the patient with and without
the service.
On completion of the PDSA cycle the nurseled pre-admission service was shown to have
achieved a reduction in patients’ nonattendanc or cancellation rate from 18% to
6%, which if made available to all patients,
could increase patient attendances by up
to 500 per year.
Page 111
6.0 Managing change
Page 112
A guide to good practice
6.1 The human dimensions
The human dimensions
No change can be achieved without the support of all those involved.
There are a number of approaches to managing the human dimensions of
change, and this is a brief introduction of some of the approaches to
involving staff in the change process.
Most people do not like change.
Implementing change successfully
inevitably means working with people who
would prefer things to continue as they
are. How is it possible to get people to
not only cooperate with the change
process, but to be enthusiastic about it?
Top down versus bottom up
Change can be imposed by management,
or it can develop organically from below.
Top down change will usually have a clear
plan, will have support and leadership,
and will have clear objectives. On the
other hand, staff will see the change
process as imposition from above and they
are less likely to feel part of the process.
Bottom up change will be more inclusive
of staff, because this is change from
“within the ranks”. It is likely to be a
continuous, rather than an episodic,
process. There is often no plan or clear
objective to the change. Outcomes may
not be supported by senior management,
as they may not fit with organisational
objectives. There is less likely to be senior
management acceptance of solutions.
The best option is a combination of the
two approaches. Clear leadership and
support for the process from
management, with clear objectives. Staff
A guide to good practice
should be using improvement tools in their
daily work, and change should be a
continuous process.
Change will be encouraged by “intelligent
leadership*”. Clinicians are more likely to
become involved in change if they are
confident that managers understand the
problems faced by the service, and are
competent in the analysis and
understanding of data.
The four essential factors
Before staff will encompass change there
are four factors that must be present.
Dissatisfaction
Staff must be unhappy with the process
as it currently is. No one will want to
change something that they think is
working well.
Vision
There must be a view that things can be
better, and an agreed vision of how things
could be. We do not give up what we have
without a clear idea of what we will put
in its place.
Capacity
There must be capacity to change. There
must be a commitment from management
*
Alistair Mant. Intelligent Leadership.
Page 113
6.1 The human dimensions
to the change process and to providing
the resources that will be necessary to
implement the change.
Transitions
First steps
There must be a clear understanding by
all of what will happen first. Overcoming
inertia is easier if there is a clear plan,
with manageable first steps.
Every change destroys something that has
gone before, and some people will regret
that loss even if they are happy with the
new process.
The Comfort Zone
Part of involving people is getting them
out of that comfort zone where they feel
that the status quo is OK. But it must be
done in such a way that staff do not panic.
In any group there will be those in the
comfort zone (I don’t want to change),
and those in the panic zone (I can’t
change). The art is in moving both into
the discomfort zone (I can change).
The Panic Zone
The Discomfort
Zone
The
Comfort
Zone
Figure 53. Moving the zones
What is in it for me?
The best way to move people is to identify
what is in the change process for them.
Everyone will have some motivation for
either adopting or resisting change.
Everyone will have something about the
current process that they do not like. The
key of good change management is to
identify and use these drivers. Ensure that
solutions to problems meet the needs of
the staff, and they will be much easier to
implement.
“Every beginning ends something”
— Paul Valery, French poet
William Bridges* calls the process that
people go through as they face change
“transition”. Transitions start with an
ending, go through a period of
uncertainty, and end with a new
beginning.
1. Managing the ending
Before you can start something new, you
must end what used to be. To do this
effectively you must understand who is
losing what? What is over? You must
positively acknowledge the losses and be
clear what is over and what isn’t.
It is often useful to ritually mark endings.
In some cases, you can let people take a
bit of the past with them — their door
sign, their desk, a plant or poster.
2. Managing the neutral zone
Neither the old ways nor the new ways
seem to be working. This is the dangerous
time, where anxiety rises and motivation
falls. There will be more illness, but it is
also a more creative time — redefine it
and use it constructively. Create
temporary systems to manage through this
stage.
3. A new beginning
This is the easy part, especially if the
endings have been managed. You must
clarify and communicate the purpose,
painting a picture of how it will be. Create
a plan, and show everyone their part in
the future.
*
Page 114
William Bridges. Managing Transitions — Making
the Most of Change. Perseus Books 1991
A guide to good practice
6.2 PDSA cycles: A model for improvement
PDSA cycles:
A model for improvement
After analysis, after identifying the problems, comes the moment of truth.
What can be done to improve the service? How can changes be introduced
in a clinical environment so that staff feel comfortable and patient care
is improved not disrupted. Traditionally, the NHS approach to change has
been through project management. Project plans are produced, Gantt
charts prepared, programmes of meetings arranged. Change is introduced,
but meets opposition and does not always succeed.
Innovations in Care recommends an
alternative approach to introducing
change. A process of continuous
improvement through incremental
change, the use of PDSA cycles provides a
model of improvement that enables an
ongoing change programme to exist in a
clinical environment.
What is the PDSA model?
The model for improvement has two parts:
it starts with three questions, followed
by a series of improvement cycles.
1. What are we trying to accomplish?
The start of the improvement process
should be statement of the aims of the
project. It is impossible to reach a goal
without knowing what it is. The goal
statement should be clear, specific,
aspirational and measurable.
2. How will know that a change is an
improvement?
The key to an effective improvement
process is measurement. Without
effective measures there is no way to
know whether any change is improving the
process. Selection of a range of measures
for improvement should be central to any
improvement process.
A guide to good practice
3. What changes can we make that
will result in improvement?
The PDSA cycles are a way of testing
suggested improvements in a controlled
environment. The changes that are
developed in response to question 3 are
the changes that the cycles will test.
Changes can come from staff suggestion,
from other sites who have looked at the
same problems, or from the literature.
Innovations in Care is developing a
database of good practice which can also
be used as a source of ideas.
The PDSA Cycle
The PDSA cycle is a repeated cycle of four
stages.
Plan
Define the question that you want
answered in this cycle, including what you
would expect the outcome to be
expected. Design an experiment to test
the question, covering the “who, what,
when and how” of the cycle, and the
measures that will be used to determine
success.
Do
Do the experiment, ensuring the data has
been collected. Record what went wrong,
Page 115
6.2 PDSA cycles: A model for improvement
and what went well.
Were there any
unexpected
outcomes?
What are we trying to accomplish?
Study
Get everyone together
to look at the data.
What
has
been
learned? Do the
outcomes agree with
the predictions? Are
there circumstances
where the outcome
might be different?
What changes can we make that will
result in an improvement?
How will we know that a change is
an improvement?
Plan
parallel with another
series dealing with a
different problem,
but the key is to have
a series of changes,
made in a systematic
fashion,
with
evidence of the
results from each
cycle, over a period of
time.
The
PDSA
Cycle
Advantages of PDSA
The PDSA model is
Do
ideally suited to
introducing change in
a complex clinical
Act
environment, where
Decide what to do
there is a high
Study
next cycle . Should the
element of risk. Small
change be impleFigure 54. The PDSA Cycle
changes are more
mented more widely?
acceptable to staff
Can it be extended to more patients, or
and patients, and there is far less
is something else necessary? What will be
disruption than the more traditional
the objective of the next cycle? If the
“major redesign programme”. The process
change was unsuccessful, it should be
also promotes the philosophy that change
abandoned and something different tried
is a normal continuous process that the
for the next cycle — there should not be
staff are involved in, rather than a major
pressure to adopt every change.
event that “happens” to people.
Act
A series of cycles
Improvement is the result of a continual
series of cycles building on previous
results. Each PDSA cycle is short, making
small improvements the status quo. The
result is a steady improvement in process
over time. One “ramp” of cycles relating
to one process may be undertaken in
PDSA REPORT
This page should be completed for each cycle. Either photocopy the sheet or use the
electronic version supplied.
Date cycle completed
What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will result in an improvement?
Objectives of
this cycle
Cycle
Number:
P
A
P
A
P
A
P
A
P
A
Cycle
1
Cycle
2
S
Cycle
3
Cycle
4
Cycle
5
D
S
What
D
Where
S
D
S
D
Questions to be
answered (predictions)
Details of the plan:
Who
A process of continual
improvement
When
Carry out the plan. Collect the Data. Begin the analysis of the data as it is
collected
Observations in
carrying out the plan:
What was unplanned?
D
S
Figure 55. Improvement: A series of cycles
Page 116
Figure 56. A recording form...
A guide to good practice
6.3 Reducing follow-up demand
Reducing
follow-up demand
One of the main pressures on outpatient clinics is the volume of followup appointments. Regular follow-ups are seen as a high priority by many
staff, often taking priority over new referrals into a clinic. It is common
for new referrals to be cancelled when space for follow-ups is tight, and
this leads to increased waiting times for new referrals. Reducing followup attendances is the quickest way of increasing capacity within an
outpatient clinic.
There are many ways to reduce follow-up The basic technique is to set up a data
attendance. In some cases, it is simply a collection tool that can be applied to
matter of understanding the impact of every patient seen in a department in a
follow-up appointments, and deciding as typical week. This data can be collected
a multi-disciplinary team that the from the PAS, from patient records, and
situation needs to be reviewed. In other from checklists completed by staff during
cases, more formal
approaches to reviewing
the situation will be
Nurse Practitioner in ENT
useful.
Cardiff and Vale NHS Trust
Understanding clinic
profiles
It can be difficult to see
the wood from the trees.
Sometimes it is necessary
to step back and review
what is happening in
outpatient clinics as a
concerted exercise,
rather than relying on
perception and anecdotal evidence.
One way of doing this is
to create a “Week in the
life of a clinic” to
determine just what
happens during a typical
week.
A guide to good practice
In common with many other Trusts in Wales, Cardiff and Vale
has long waiting times for ENT and Audiological Medicine.
The longest waiting patients are those with routine conditions
whose needs inevitably have to be prioritised against those
with urgent conditions including actual or suspected cancers.
A nurse practitioner was appointed in July 2002 with the
specific objective of improving access times to the service.
Following a period of training and development of care
pathways and treatment protocols, she now works
autonomously and provides assessment, diagnosis and
treatment for patients referred from consultants and junior
medical staff and GPs, and those she is able to select directly
from the waiting list. Conditions the nurse practitioner is
able to diagnose and treat include assessment of hearing loss,
mastoid cavity care, aural care and treatment of infections,
assessment for tonsillectomy and recurrent epistaxis.
The nurse practitioner’s annual capacity is 2550 new
outpatients, and 1000 follow-ups. For the patients she is able
to treat, this has enabled a reduction in waiting times from
38 months to 2 months for one consultant, and to between
11 and 3 months for the other four.
Page 117
6.3 Reducing follow-up demand
the clinic. Each of these will give a part
of the picture:
From the PAS
Patient demographics including age/sex
profiles, postcode analysis, referrer
analysis.
From the patient record
Diagnosis and co-morbidities, number of
times the patient has attended in the last
year.
From a checklist
Who saw the patient, action taken, tests
ordered, when the next appointment will
be.
The information collected from these
sources over a typical week should give
enough data to be statistically significant.
Combining the data into a single database
will allow collation across the different
sources. The aim of the collection exercise
should be to provide a picture of a typical
cross section of patients seen in the
department, and should help in answering
a number of questions such as: what
proportion of patients are local? What is
the level of co-morbidity? What disease
groups make up the highest proportion of
frequent attenders? How many of the
follow-up appointments were seen by
junior staff, and what were the decisions
taken?
The analysis may not provide any quick
answers, but it will contribute to any
subsequent improvement process. Without knowing the nature of the thing that
is to be improved, there is a danger of
concentrating on what seems obvious, or
what “everyone knows is the problem”.
Good data on the current situation is the
first step to improvement.
This exercise can take a significant
resource. Collection will involve looking
at patient notes, and staff completing
checklists for every patient they see
Page 118
during the week. The benefits are well
worth the effort, as no-one can say that
they are managing a service if they do
not understand what is happening within
that service.
Frequent attender analysis
A combination of analysis and action, this
technique is a way of focussing efforts on
the patients where the most return is
likely.
From at least a year’s data download from
the PAS, do a frequency analysis of
attendances by patient. The only data
required for this is the patient number
and the date of the outpatient
appointment. Within a spreadsheet, a
pivot table can be used to count the
number of attendances by each patient.
The pivot table can then be used to count
the number of patients who had one
appointment, two appointments and so
on.
This is likely to show that the number of
patients with significant multiple
appointments is low, but that the number
of appointments taken up by those
patients is significant. In figure 57, which
represents data for two years, one patient
had 28 appointments, and three had 24
or 25 (one every month). In all, 18 patients
(0.20%) accounted for 343 appointments
(1.81%), while 125 patients (1.40%) had
10 or more appointments over the two
years, representing 1,615 appointments
(8.53%).
What can be done with this data? Pulling
the patient records of the 18 patients and
doing a clinical review may reveal changes
to the care which would result in fewer
appointments. Are these patients being
best managed in outpatients? Would there
be benefit in meeting with the patient’s
GP? By focussing on patients who are
frequent attenders it may be possible to
customise their care and improve the
A guide to good practice
6.3 Reducing follow-up demand
Frequency of Attendance, 2 years data
Number of
patients
Attendances
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
% of Patients
Cumulative %
of Patients
53%
22%
11%
6%
3%
1%
1%
1%
1%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
53%
76%
86%
92%
95%
96%
97%
98%
99%
99%
99%
99%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
4761
2005
959
530
259
117
92
59
48
26
27
19
14
10
11
4
6
1
3
0
0
0
0
1
2
0
0
1
0
0
8955
Number of
attendances
% of
attendances
4761
4010
2877
2120
1295
702
644
472
432
260
297
228
182
140
165
64
102
18
57
0
0
0
0
24
50
0
0
28
0
0
18928
25%
21%
15%
11%
7%
4%
3%
2%
2%
1%
2%
1%
1%
1%
1%
0%
1%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
Cumulative %
of
attendances
25%
46%
62%
73%
80%
83%
87%
89%
91%
93%
94%
96%
97%
97%
98%
99%
99%
99%
99%
99%
99%
99%
99%
100%
100%
100%
100%
100%
100%
100%
Figure 57a. Frequent attendance data, 2 years clinics
Percentage of patients and attendances
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Frequency of attendance
% of Patients
% of attendances
Cumulative % of Patients
Cumulative % of attendances
Figure 57b. Distribution of patients and appointments by frequency
A guide to good practice
Page 119
6.3 Reducing follow-up demand
outcome, while also reducing the demand
on outpatients. The key is identifying the
small number of patients who are
consuming relatively large amounts of
clinic time, and then seeing if they can
be managed better.
Use of “SOS” appointments
Many departments now use self referral
for follow-up rather than fixed
appointments. This can be very effective
in reducing both follow-up appointments
and DNA rates in some situations. So called
“SOS” appointments can be used to
advantage where the patient has a
recurrent problem, where a procedure is
being followed up, or where monitoring
of a chronic condition can be undertaken
in part by the patient.
Recurrent problems
This is the most common use of SOS
appointments now. There is little point in
regular follow-up of a condition which
flares up from time to time, rather it is
preferable to have rapid access to an
appointment when the problem recurs.
Procedure follow-up
In many situations it is common to recall
patients while they are recovering from a
procedure. Often appointments are made
on a regular basis, until the patient
reports no further problems. This will
always result in one more appointment
than necessary (when the patient attends
to report no symptoms) and often more
than one appointment.
Informing the patient about the
progression of recovery (through a patient
pathway), and allowing the patient to
make an appointment quickly if there is a
deviation from the pathway or if the
patient has any concerns, will mean that
patients on the normal recovery path will
not take up clinic time, which can then
be devoted to those patients with
problems.
Page 120
Chronic condition monitoring
Patients with chronic conditions can also
use SOS appointments, with the possibility
of less frequent scheduled review.
In the case of chronic conditions, as with
procedure follow-up, it is essential that
the patient understands what events
should trigger an appointment. Laminated
cards with the events that should lead to
an SOS appointment and instructions on
how to make one are used with many
patients.
Care must be taken with chronic
conditions that have trigger events not
apparent to the patient. Examples of
these may be glaucoma or diabetic
retinopathy in ophthalmology, or
cholesterol levels in cardiology. In these
cases, where the patient cannot monitor
their own health, non-consultant
monitoring can be used to reduce
attendances in the outpatient clinic.
Follow-up referral protocols
Many attempts have been made to reduce
referrals through the use of primary care
referral protocols. Yet few departments
have explicit protocols relating to the
generation of a follow-up appointment
although unnecessary follow-up appointments make up a higher proportion of
clinic time than unnecessary new
referrals.
Where junior staff review patients, the
development and use of explicit protocols
on the need to bring patients back to clinic
will significantly reduce follow-up
appointments. Junior staff have a
tendency to bring patients back if in doubt
— protocols make explicit when a patient
should be brought back (or given an SOS
appointment.
All departments should develop follow-up
protocols for their major patient groups,
and monitor their use.
A guide to good practice
6.4 GP feedback systems
GP feedback systems
When talking to consultants and GPs about direct access to outpatient
appointments, two things become clear. Consultants are concerned about
the number of referrals wrongly directed, with inadequate information,
uncompleted tests, or wrongly prioritised. GPs are concerned about
receiving feedback on the quality of, or problems with, referrals. There
should be a process to address these concerns. Innovations in Care
recommends the following approach.
Using clinical guidelines the GP
determines if the patient requires an
appointment within. The guidelines are
not restrictive — they give guidance, but
do not override clinical judgement.
The GP then uses the Trust Appointment
Centre to make an appointment if the
appointment is needed within six weeks.
This is done with the patient present, and
the appointment is arranged to the
patient’s convenience.
A referral form is faxed through to the
appointment centre within 48 hours (if it
is not received the Appointment Centre
will contact the practice.) The consultant
does not need to see the referral until
the patient attends the clinic, but may
choose to do so.
Consultant
and GP
agree
guidelines
GP uses
guidelines to
determine
priority
Figure 58. Flow chart of the GP feedback system
A guide to good practice
At the time the patient attends the
appointment an evaluation form is
completed (see page 122).
The evaluation form is returned to the GP.
A summary of the data on the form is also
returned on a regular basis to the LHG
clinical governance structure.
Issues with specific GPs are the
responsibility of the LHG. General
diagnostic or referral problems are the
responsibility of the Trust, and should be
addressed through a GP education
programme.
This process will improve the quality of
referrals through a positive feedback
process, rather than the more restrictive
use of protocols to limit access.
Appointment
made by GP
Consultant
completes
evaluation
Feedback to GP and LHB
Clinical Governance
Committee
Page 121
6.4 GP feedback systems
GP Referral Feedback Form
Hospital Number: 123987
Patient Name:
Master David
ConsultantMr Earsay
Referral Source
Specialty ENT
Referral Type Urgent
Date Received3 Feb 2001
Seen By:
Consultant
GP Direct Access
Areas above the
line are pre-filled
by the computer
Appointment Date 23 Feb 2001
Assoc. Specialist
Registrar
SHO
Was the referral appropriate?
Yes
No
If no, should it have been
Urgent
Routine
2 week cancer wait
Italics completed
in clinic
Was the referral according to any available guidelines?
Yes
No
No Guide
Comments
This referral was not appropriate because
the child’s symptoms were chronic, not
acute
Dr Walton
Seen By
Summary completed by
Figure 59. Feedback form.
Page 122
A guide to good practice
Chapter 7
Useful resources
This document provides a very brief introduction to a number of different
tools and techniques. It is hoped that the following resources will allow
you to delve deeper into some of the tools and learning resources.
A good starting place for more information is the Innovations in Care website:
howis.wales.nhs.uk/inic
Government Publications
Improving the Health in Wales: A Guide for the NHS with its Partners
Welsh Assembly Government, 2001.
The Review of Health and Social Care in Wales
Report of the Project Team advised by Derek Wanless. Welsh Assembly
Government, June 2003.
Waiting List Accuracy: Assessing the Accuracy of Waiting List Information in NHS Hospitals in
England and Wales
The Audit Commission, March 2003.
Audit Commission Acute Hospital Portfolio Report on Operating Theatres
The Audit Commission, June 2003.
Copying Letters to Patients: Summaries of 12 Pilot Project Sites
Health Organisations Research Centre, Manchester School of Management, 2003.
Healthcare Improvement
To Err is Human: Building a safer health system
Institute of Medicine report, National Academy Press, 2000
Crossing the Quality Chasm
Institute of Medicine report, National Academy Press, 2001
Curing Healthcare. New Strategies for Quality Improvement
Donald M Berwick, A Blanton Godfrey, Jane Roessner. Jossey-Bass, 1990
Escape Fire. Designs for the Future of Health Care
Donald M Berwick. Jossey-Bass, 2004
A guide to good practice
Page 123
7.0 Useful resources
Modernisation Agency Publications
Clinically Prioritise and Treat: The CPAT Step Guide
Clinically Prioritise and Treat: The CPAT Toolkit Guide
Ready Steady Book: A Guide to Implementing Booked Admissions & Appointments.
Modernisation Agency: Improvement Leaders Guide Volume 1 and Volume 2
1
Process Mapping, analysis and redesign
2
Matching capacity and demand
3
Measurement for improvement
4
Spread and sustainability
5
Involving patients and carers
6
Managing the human dimensions of change
7
Setting up a collaborative programme
Step by Step Guide to Improving Operating Performance.
The National Booking Programme: Access Booking and Choice. Annual review 2002.
Achieving Real Improvement for the Benefit of Patients: NHS Modernisation Agency Annual
Review 2002/2003.
Quality Improvement
The Improvement Guide: A Practical Approach to Enhancing Organisational Performance
Langley, Nolan, Nolan, Norman & Provost.ISBN 0-7879-0257-8
Quality Improvement Through Planned Experimentation
Moen, Nolan, & Provost. ISBN 0-07-913781-4
The Fifth Discipline: The Art and Practice of the Learning Organisation
Peter Senge. ISBN 0-09-182726-4
The Fifth Discipline Fieldbook
Peter Senge. ISBN 1-85788-060-9
The Dance of Change: The Challenges of Sustaining Momentum in a Learning Organisation (a
Fifth Discipline Resource)
Peter Senge. ISBN 1-85788-243-1
Understanding Variation: The Key to Managing Chaos (2nd Edition)
Donald J Wheeler. ISBN 0-94532-053-1
The Memory Jogger Plus+ and Featuring the Seven Management and Planning Tools
Michael Brassard. ISBN 1-879364-41-7.
Promoting Advanced Access in Primary Care: A handbook
Thomas S Warrender. ISBN 1-902115-25-2.
Lean Thinking: Banish Waste and Create Wealth in Your Corporation (revised)
James P Womack and Daniel T Jones. ISBN 0-74324-927-5
The Lean Toolbox.
John Bicheno. ISBN 0-9513-829-9-3
Page 124
A guide to good practice
7.0 Useful resources
Presenting Information
Visual Explanations
Edward R Tufte.ISBN 09613921-2-6.
The Visual Display of Quantitative Information
Edward R Tufte. ISBN 0-9613921-0-X.
Envisioning Information
Edward R Tufte. ISBN 0-9613921-1-8.
Leadership Skills
Intelligent Leadership
Alistair Mant. ISBN 1-86508-052-7
Leading Change
John P Kotter. ISBN 0-87584 –747-1
Managing Transitions: Making the most of change
William Bridges. ISBN 0-20100-082-2
The Theory of Constraints
The Goal
Eliyahu M Goldratt. ISBN 0-88427-061-0
It’s Not Luck
Eliyahu M Goldratt. ISBN 0-566-07627-6
Critical Chain
Eliyahu M Goldratt. ISBN 0-88427-153-6
Necessary but Not Sufficient
Eliyahu M Goldratt. ISBN 0-88427-170-6
Project Management in the Fast Lane: Applying the Theory of Constraints
Robert C Newbold. ISBN 1-57444-195-7
Goldratt’s Theory of Constraints: A Systems Approach to Continuous Improvement
H William Dettmer. ISBN 087389-370-0
What is this Thing Called the Theory of Constraints and How Should it be Implemented
Eliyahu M Goldratt. ISBN 0-88427-085-8
The Haystack Syndrome
Eliyahu M Goldratt. ISBN 0-88427-089-0
Deming and Goldratt: The Theory of Constraints and the System of Profound Knowledge
D. Lepore and O Cohen. ISBN 0-88427-163-5
Management Dilemmas: The Theory of the Constraint Approach to Problem Identification and
Solutions
Eli Schragenheim. ISBN 1-57444-222-8
The Measurement Nightmare: How the theory of Constraints can Resolve Conflicting Strategies,
Policies, and Measures
Debra Smith. ISBN 1-57444-246-5
Critical Chain Project Management
Lawrence P Leach. ISBN 1-58053-074-5.
A guide to good practice
Page 125
7.0 Useful resources
Websites
howis.wales.nhs.uk/inic
The Innovations in Care Team website.
www.modern.nhs.uk
This is the NHS modernisation agencies official website.
www.modern.nhs.uk/scripts
This is the web address for the modernisation agency pre-operative assessment guidance.
www.modern.nhs.uk/cpat
This is the web address for the Clinically Prioritise and Treat Programme.
www.modern.nhs.uk/theatres
Modernisation Agency Operating Theatre and Preoperative Assessment website.
www.modern.nhs.uk/theatreprogramme
This website contains electronic copies of the following documents:
·
Step guide to improving operating performance
·
Theatre programme diagnostic tools and user manuals
·
Audit commission theatre kit.
www.ihi.org
The Institute of Healthcare Improvement website.
www.chl.wales.nhs.uk
The Centre for Health Leadership Website.
www.doh.gov.uk/patientletters/issues.htm:
Good practice guidelines for “copying letters to patients” in England.
www.doh.gov.uk/waitingbookingchoice
The Department of Health Waiting, Booking and Choice programme website.
howis.wales.nhs.uk/Microsite/page.cfm?orgid=296&pid=5803
Cancelled Operation Reports.
www.audit-commission.gov.uk
The Audit Commission website.
www.nice.org.uk
The National Institute for Clinical Excellence website.
www.his.org.uk
The Hospital Infection Society website
www.natn.org.uk
The National Association of Theatre Nurses website.
www.aodp.org
The Association of Operating Department Practitioners.
www.cf.ac.uk/carbs/lerc
The Lean Enterprise Resource Centre at Cardiff University.
www.qualityhealthcare.com
Quality and safety in healthcare — a journal.
www.lean.org
The official website of the Lean Enterprise Institute.
www.goldratt.co.uk
The official Goldratt UK website.
www.jeantodd.co.uk.
The Jean Todd Partnership (Appointment Centre training).
www.brecker.com/quality.htm
The Continuous Quality Improvement movement of Deming and Juran.
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A guide to good practice